Major depressive disorder affects millions of people across the United States, causing persistent sadness, loss of interest, and other debilitating symptoms that can last for years before effective treatment is found.
“According to the World Health Organization, MDD was the third leading cause of the global burden of disease in 2008 and is projected to rank first by 2030”.
For healthcare providers, treating this complex condition is further complicated by the challenges of administering and billing for newer therapies like Spravato. In 2026, Spravato billing remains one of the most complex reimbursement tasks, with
- Strict REMS requirements
- Payer-specific coding rules
- Evolving insurance policies
Even small documentation errors can lead to claim denials.
This guide provides a comprehensive breakdown of Spravato billing guidelines for 2026, including CPT and HCPCS codes, Medicare and commercial insurance coverage, documentation requirements, and compliance considerations for certified facilities.
Spravato Billing Guidelines 2026
CPT Codes for Spravato Administration
Billing for Spravato requires specific procedure codes. The primary code is 96377 for the first session. This covers therapeutic drug administration for intranasal use.
Each treatment session uses this code once. The code includes the observation time and monitoring. Documentation must clearly show the two-hour supervision period.
For the drug itself, providers use HCPCS code S0013. This represents esketamine nasal spray per dose. The number of units billed depends on the strength administered.
Documentation Requirements
Proper documentation is crucial for reimbursement. Records must show treatment-resistant depression diagnosis. Charts should include evidence of previous failed medication trials.
Each session note needs several key elements. Document the exact dose administered. Record vital signs before and after treatment. Note any adverse reactions or side effects observed.
Include the full two-hour observation period in your notes. Describe the patient’s mental state throughout. Document who provided supervision. These details support medical necessity.
Prior Authorization Process
Most insurance plans require prior authorization. Submit clinical notes showing treatment resistance. Include medication history with specific drugs tried and outcomes.
Authorization requests need clear justification. Explain why standard treatments failed. Provide symptom severity scores. Include any suicide risk assessments.
The approval process takes one to three weeks typically. Some plans approve quickly, others take longer. Denials can be appealed with additional documentation.
Frequency Limitations and Coverage
Insurance companies limit treatment frequency. Most cover twice-weekly dosing during induction. This initial phase runs four weeks or eight sessions.
After induction, coverage continues for maintenance. Weekly sessions are standard for the next month. Then treatment reduces to every other week.
Some plans cap total sessions per year. Others require periodic reassessment. Ongoing authorization may need symptom tracking data. Response to treatment must be documented clearly.
Facility Requirements for Billing
Only certified facilities can bill for Spravato. Providers must complete REMS training. This Risk Evaluation and Mitigation Strategy ensures safe use.
The treatment space needs appropriate monitoring equipment. Blood pressure cuffs and pulse oximeters are essential. Emergency equipment should be readily available.
Staff training documentation affects billing eligibility. Keep certification records current. Update REMS status as required. These compliance factors impact reimbursement.
Medicare and Medicaid Considerations
Medicare covers Spravato under Part B. The drug falls under the medical benefit, not pharmacy. This affects patient cost-sharing responsibilities.
Medicaid coverage varies by state. Some states have generous policies. Others impose strict limitations. Check your state’s specific guidelines before treating Medicaid patients.
Both programs require extensive documentation. Medical necessity standards are high. Peer-to-peer reviews sometimes occur. Be prepared to justify treatment decisions.
Commercial Insurance Policies
Private insurers each have unique policies. Blue Cross, Aetna, UnitedHealthcare—all differ. Review each plan’s medical policy before billing.
Some commercial plans cover Spravato readily. Others create multiple hurdles. High deductibles may apply. Prior authorization is nearly universal.
Patient out-of-pocket costs vary widely. Copays can range from minimal to substantial. Discuss financial responsibility upfront. Many manufacturers offer patient assistance programs.
Coding for Complicated Cases
Some patients need extended observation beyond two hours. Document the medical reason clearly. Extra time may require additional codes or modifiers.
Adverse events during treatment need separate coding. Nausea requiring medication gets its own code. Blood pressure management may justify additional billing.
When patients don’t complete the full observation period, adjust coding accordingly. Document why the early departure occurred. This protects against audit issues.
How Spravato Treats Depression
Spravato is a nasal spray form of esketamine. Ketamine has been used in medicine for decades as an anesthetic. Esketamine is a specific part of the ketamine molecule. Research showed it could rapidly reduce depression symptoms.
Studies revealed impressive results. Many patients saw improvement after just one dose. The effects often lasted for days or weeks. This rapid action offers hope for people in crisis.
The medication promotes new neural connections. It appears to help the brain form healthier thought patterns. Scientists continue studying exactly how this process works.
Spravato represents a breakthrough in depression treatment. The generic name is esketamine. Unlike traditional pills, this comes as a nasal spray. The drug works through a completely different mechanism than standard antidepressants.
The FDA approved Spravato in March 2019. It’s specifically for treatment-resistant depression in adults. Later, the FDA expanded approval for acute suicidal thinking in depressed patients.
How Spravato Treatment Works
- Spravato isn’t something patients take at home.
- Treatment happens in certified healthcare settings.
- A medical professional must observe the entire process.
- Patients self-administer the nasal spray under supervision.
They use the device to spray medication into each nostril. The typical starting dose is 56 milligrams. Some patients need 84 milligrams.
Treatment starts with twice-weekly sessions. This induction phase lasts four weeks. After that, dosing is reduced to weekly, then every other week. The schedule depends on individual response.
Required Observation Period
Patients must remain at the facility for two hours after dosing. This monitoring is mandatory, not optional. Healthcare staff watch for side effects and dissociative symptoms.
Common immediate effects include dizziness, nausea, and sedation. Some people feel detached from reality temporarily. Blood pressure often rises during treatment. These effects typically fade within the observation window.
Patients cannot drive themselves home after treatment. They need someone to pick them up. Operating machinery is unsafe for the rest of the day.
Combining with Oral Antidepressants
Spravato isn’t a standalone treatment. Patients must continue taking their regular oral antidepressant. The nasal spray works alongside existing medications.
This combination approach maximizes benefits. The oral medication provides baseline support. Spravato targets resistant symptoms that pills couldn’t touch.
Conclusion
Spravato represents real hope for people suffering from treatment-resistant depression. The medication works differently from traditional options. It offers rapid relief for many who’ve struggled for years.
Billing for Spravato requires attention to detail. The guidelines are specific and strictly enforced. Proper coding, documentation, and authorization make the difference between payment and denial. Healthcare providers must balance clinical care with administrative requirements. Strong systems support both goals. Invest in training, technology, and processes that ensure success.
The 2026 billing landscape continues evolving. Stay informed about policy changes. Build relationships with payers and billing experts, such as Connecticut Medical Billing. Working with us makes the process easier, and the right billing support helps clinics focus more on patient care.
FAQs
Will Medicare cover SPRAVATO?
Medicare covers FDA-approved esketamine (Spravato) treatments for treatment-resistant depression under Part B or Part D, depending on how it’s administered
How to bill SPRAVATO?
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.
What disqualifies you from SPRAVATO?
SPRAVATO (esketamine) is contraindicated (should not be used) in patients with aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or hypersensitivity to esketamine, ketamine, or excipients.
Does Blue Cross Blue Shield cover Spravato?
Does insurance cover it, and more specifically, does BCBS cover Spravato? Blue Cross Blue Shield (BCBS) generally covers Spravato (esketamine) for treatment-resistant depression (TRD).