How to document a TMS session

A TMS note has to prove this session happened, on this device, with these parameters, and that someone licensed still owns the course. Payers reauthorize mid-protocol. Identical copy-forward notes across 90868 days are the usual denial. Chart the code, the motor threshold in force, what you delivered, how the patient tolerated it, and where the PHQ-9 (or HAM-D) sits on the course.

The session skeleton in the library is TMS course note.

Pick 90867, 90868, or 90869 before you write

Write the CPT in the header so the note and the claim match.

90867 is the initial session of a course: cortical mapping, motor threshold determination, delivery, and management. Report it once per course. Do not pair it with 90868 or 90869 on the same day.

90868 is subsequent delivery and management when you did not redetermine motor threshold.

90869 is subsequent motor threshold re-determination plus delivery. Use it when sleep, a medication change, a break in treatment, or poor response makes the old MT unreliable. Do not also bill 90868 that day.

A mapping-only visit that does not deliver treatment is not a 90868. If you only remapped and sent the patient home, say so and bill what you actually did.

Chart the pre-session screen

The pre-session block answers “was it safe to treat today?”

Document interval mood, headache or scalp pain since last session, sleep last night, new meds (especially seizure-threshold drugs, stimulants, bupropion dose changes), alcohol, and any missed oral antidepressant doses if the patient is still on one.

Contraindications belong in prose the first time they are reviewed for this course, and as a one-line reaffirmation later: no implanted ferromagnetic metal in the head, no uncontrolled seizure disorder, patient remains a candidate.

If this is a checkpoint session, put the PHQ-9 (or HAM-D / IDS-SR) here with the total, the prior total, and item 9. PHQ-9 and GAD-7 scoring covers how to keep that number structured.

Record mapping, motor threshold, and delivered parameters

For 90867 (and for 90869), write the mapping method and the site (beam-F3, 5.5 cm rule, neuronavigation, deep H1, or other), the MT method (visual twitch vs EMG), the resting motor threshold as a percent of machine output, and the treatment intensity as a percent of MT.

Every delivery session, including 90868, needs today’s parameters: frequency in Hz, train duration, inter-train interval, number of trains, pulses per train, total pulses delivered, coil type, and treatment time. Name the device. “TMS provided” does not survive a recoupment.

If intensity was reduced for pain, write the original target, the reduced percent, and whether you returned to target.

Note what happened in the chair

Describe tolerance in a full sentence.

Pain or discomfort 0 to 10, twitching, nausea, near-syncope, and any seizure-like event. If nothing happened, “no adverse events; discomfort 2/10 at the coil site, resolved by end of session” is enough. If something happened, write the time, the intervention, and whether treatment finished.

Post-session: headache, mood in the patient’s words, ambulation, and whether they were cleared to drive. TMS is not Spravato; you still need a discharge line if they are dizzy or photophobic.

Close with course trend and the next session

The assessment is the course, not only today. Session number of planned total, scale trend, functional change (work, sleep, SI), and whether you are still on the authorized protocol.

The plan names the next session date, any parameter change, and whether a reauthorization packet is due. First-and-last-visit charts fail medical-necessity review because the middle of the course is empty.

Sample session block

CPT: 90868 (subsequent delivery; MT last determined 2026-04-20)
Session: 12 of 36. Protocol: 10 Hz left DLPFC, NeuroStar, figure-8 coil.
Site: beam-F3. Intensity: 120% MT (MT 58% output).
Parameters: 4.0 s trains, 26 s ITI, 75 trains, 3000 pulses, 18.5 min.

Pre-session: sleep 6.5 h, no new meds, mild scalp soreness resolved overnight.
PHQ-9 today 11 (was 16 at session 1, 13 at session 7). Item 9 = 0.

During: discomfort 3/10 first three trains, then 1/10. No AE.
Post: ambulating independently, driving cleared, no headache at discharge.

Assessment: ongoing course for recurrent MDD, severe, failed two antidepressants
plus augmentation. Partial response. Tolerating protocol.
Plan: continue 120% MT. Session 13 tomorrow. Reauth packet at session 18.

Aria can take the interval review and the during-session comments. Motor threshold and pulse counts still have to be right in structured fields. Sign the session you ran, not last Thursday’s copy.