Reimbursement FAQs
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/healthcare provider time includes face-to-face time personally spent by the physician and/or other healthcare provider(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 healthcare providers 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. In 2020, CMS established coding and payment rules for the evaluation and management, observation, and provision of self-administered SPRAVATO® under Medicare Part B. The resulting HCPCS codes (G2082 and G2083) incorporate both the provision of the drug and professional services associated with SPRAVATO® therapy.
No. Code S0013 “Esketamine, nasal spray, 1 mg” describes only SPRAVATO® and does not include professional services. This is a product-specific billing code, intended to facilitate commercial payer claims processing for SPRAVATO®. Providers must continue to report the G codes on Medicare claims.
Will some payers still accept miscellaneous J code J3490 (Unclassified drugs) to describe SPRAVATO®?
Yes. Providers will still have the option to use miscellaneous code J3490 to describe the drug on submitted claims.
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 a specific medication, 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 local area and the patient’s benefit design.
- If SPRAVATO® is covered under both benefits, check with your patient’s insurance plan to see if medical or pharmacy is preferred.
- If SPRAVATO® is covered under the medical benefit, you may utilize the buy-and-bill pathway to acquire SPRAVATO® to treat appropriate adult patients. In the buy-and-bill model, a healthcare provider purchases a drug from a specialty distributor (SD) and, after administering the drug, the provider submits a claim for reimbursement for the drug and any other medical services associated with the treatment to the payer.
- If your patient is covered under a pharmacy benefit, you may be able to acquire SPRAVATO® through a local or national specialty pharmacy (SP), but patients covered under a medical benefit will require a medical assignment-of-benefit (AOB) to acquire SPRAVATO® through a pharmacy pathway.
Learn more about the different Pathways to Acquire SPRAVATO®
Pathway to Acquire SPRAVATO® Through an Authorized Specialty Distributor
Pathway to Acquire SPRAVATO® Through a National Specialty Pharmacy
Complete List of Authorized SPRAVATO® Full-Line Wholesalers and Specialty Distributors
For more information, please contact your local account representative
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.