Spravato (esketamine nasal spray) represents one of the most significant advances in treatment-resistant depression in a generation. But for many psychiatric practices, the billing process for this drug is one of the most complex they’ve ever encountered.
This Spravato billing guide is designed to give prescribing psychiatrists, PMHNPs, and their billing teams a clear, step-by-step roadmap, covering HCPCS codes, Medicare and Medicaid coverage, prior authorization requirements, REMS obligations, documentation best practices, and how to handle denials.
Get it right, and Spravato can be a financially sustainable treatment offering in your practice. Get it wrong, and you’re looking at claim denials, revenue clawbacks, and potential compliance violations.
Why Spravato Requires Special Billing Attention
Spravato (esketamine) received FDA approval in March 2019 for treatment-resistant depression (TRD), defined as inadequate response to at least two different antidepressants. In August 2020, the FDA approved a second indication: major depressive disorder with acute suicidal ideation or behavior (MDSI).
Spravato is a Schedule III controlled substance, a derivative of ketamine. Because of its abuse potential and serious post-dose adverse effects (including dissociation, dizziness, and sedation), the FDA mandates in-office administration under clinical supervision. Patients cannot take it home. They cannot self-administer. This mandatory clinical supervision creates a unique billing structure not seen with most psychiatric medications.
The drug is expensive. A single 56 mg dose costs approximately $590–$650 at acquisition before payer negotiation. For practices absorbing this cost under a buy-and-bill model, accurate and timely reimbursement is not just a billing preference; it’s a financial necessity.
REMS Requirements and Their Billing Implications
Spravato is subject to a Risk Evaluation and Mitigation Strategy (REMS) program, one of the FDA’s most rigorous risk management programs. REMS is not optional. And it directly shapes how you bill.
REMS requirements for Spravato include:
- Healthcare settings must be certified in the Spravato REMS program before administering the drug
- Prescribers must be certified in the REMS program
- Pharmacies dispensing Spravato must be certified and can only dispense to REMS-certified healthcare settings, not to retail pharmacies or patient homes.
- Each patient must be enrolled in the REMS program and provide written acknowledgment of risks.
- The patient must self-administer under direct healthcare provider supervision, meaning a clinical staff member must be present.
- Post-dose monitoring is required for at least 2 hours, including vital signs, mental status, and dissociation assessment.
From a billing standpoint, the REMS requirements mean that every Spravato session has multiple billable components: the drug itself, the medical management visit, and the monitoring period. This Spravato billing guide covers each one in detail.
The Complete HCPCS and CPT Code Framework
A single Spravato session typically generates 2–4 separate line items on a claim, depending on whether psychotherapy is provided and how the monitoring period is billed. This is why Spravato billing requires a dedicated protocol; it’s not a single-code service.
| Code | Description | Unit / Type | Key Payer Notes |
| S0013 | Esketamine nasal spray, 28 mg | Per 28 mg dose | Used by most commercial payers; verify Medicare coverage by MAC |
| J3490 | Unclassified drugs | Variable | Use when the payer has no specific code; attach clinical documentation and invoice |
| 99213 | Office/outpatient E/M, established, low-moderate complexity | Per encounter | For psychiatric medication management, low MDM or 20-29 min time |
| 99214 | Office/outpatient E/M, established, moderate complexity | Per encounter | Most common for Spravato management visits; requires adequate MDM documentation |
| 90833 | Individual psychotherapy, 30 min add-on to E/M | Per session add-on | When brief psychotherapy is provided during the same encounter, document the time |
| 90836 | Individual psychotherapy, 45 min add-on to E/M | Per session add-on | When 38-52 minutes of psychotherapy are provided alongside E/M |
| 90838 | Individual psychotherapy, 60 min add-on to E/M | Per session add-on | When 53+ minutes of psychotherapy are provided alongside E/M |
| 99217 / H0019 | Observation services / Behavioral health day treatment | Per hour or per diem | For a 2-hour post-dose monitoring period, payer-specific; verify before billing |
Medicare Coverage for Spravato: What You Need to Know
Medicare Part B covers Spravato as a physician-administered drug; it is administered in-office by or under the supervision of a clinical professional, placing it under Part B rather than Part D.
Medicare Part B coverage requirements:
- The treating provider and the facility must both be enrolled in Medicare
- The prescribing clinician and facility must be enrolled in the Spravato REMS program
- The medical record must document at least 2 adequate antidepressant trials, specify the drug name, dose, duration, and reason for failure or inadequate response.
- Current diagnosis must meet CMS’s definition of TRD or MDSI
- Claims must include the correct HCPCS code (S0013 or as specified by the Medicare Administrative Contractor for your region)
Important note: Medicare coverage rules for Spravato are administered by regional Medicare Administrative Contractors (MACs). The specific coding requirements, including whether S0013 or an alternative code is accepted, can vary by MAC. Always verify with your MAC before submitting the first claim.
Medicaid Coverage: State-by-State Variation
Medicaid coverage for esketamine treatment varies significantly by state. As of 2024, most state Medicaid programs cover Spravato for TRD, but the specific requirements differ considerably:
- Step therapy requirements: Most states require documented failure of 2–4 antidepressant trials before approving Spravato
- Prior authorization: Nearly universal, PA is required before the first treatment in virtually every Medicaid program
- Quantity limits: Some states limit the number of sessions per authorization period
- Re-authorization: Many states require clinical updates and re-authorization every 4–8 weeks
- Prescriber restrictions: Some states restrict Spravato prescribing to psychiatrists only; PMHNPs may need a physician’s co-signature
Check your state’s Medicaid formulary and PA requirements through the CMS Medicaid Drug Policy database and your state Medicaid agency’s provider portal before prescribing.
Prior Authorization: What Every PA Submission Must Include
Prior authorization for Spravato is required by virtually every payer, including Medicare Advantage, commercial plans, and Medicaid. A complete, well-documented PA request dramatically reduces denial rates and speeds up approval.
Your PA submission for Spravato must include:
- DSM-5 diagnosis, TRD (F33.x or F32.x) or MDD with MDSI (F32.x), with supporting clinical notes
- Documentation of at least 2 prior antidepressant trials: name, starting dose, maximum dose, duration, and reason for failure (inadequate response or intolerance)
- Current PHQ-9 or MADRS score demonstrating the severity of depression
- Evidence of functional impairment, how the current episode is affecting work, relationships, and daily functioning
- Attestation of REMS certification for both the prescriber and the facility
- Proposed treatment plan, frequency, duration, and monitoring protocol
- For MDSI, documentation of active or recent suicidal ideation, ideally with the Columbia CSSRS score
A complete, well-organized PA packet reduces the average commercial payer approval timeline from 7–14 days to 3–5 days. Practices with high PA approval rates invest in clinical documentation templates specifically designed for Spravato prior authorization.
Step-by-Step: How to Bill a Complete Spravato Session
Start by preparing your billing workflow. Ensure all staff involved in the Spravato session, clinical, pharmacy, and billing, understand payer rules, REMS requirements, and proper documentation standards to prevent denials. Verify inventory and session scheduling align with your claims submission plan.
Before the Session
Verify PA approval is active and has not expired. Confirm the patient’s insurance eligibility for the date of service. Obtain Spravato from your REMS-certified pharmacy or 340B program and document acquisition cost if billing under buy-and-bill.
Step 1: Bill the Drug (HCPCS)
Submit the appropriate HCPCS code for the esketamine dose administered. A standard session uses 56 mg (two 28 mg doses), so bill two units of S0013 if billing per 28 mg. Include the National Drug Code (NDC) on the claim line when required by your payer. The NDC for Spravato nasal spray (esketamine 28 mg) is 50458-0028-02.
Step 2: Bill the E/M or Psychiatric Management Visit
The prescribing psychiatrist or PMHNP should document and bill the medical management component using the appropriate E/M code. Select the level based on documented Medical Decision Making (MDM) or time. Most Spravato management visits support a 99214, given the moderate complexity of ongoing TRD management.
Your documentation should address: patient’s response to previous Spravato sessions, current symptom status (PHQ-9 or MADRS score), adverse effect assessment, medication adjustments if any, and clinical rationale for continuing or modifying the treatment plan.
Step 3: Bill the Monitoring Period
The 2-hour post-dose monitoring requirement must be documented AND billed. Monitoring documentation should include: time of drug administration, vital signs at 30-minute intervals, dissociation assessment using CADSS or clinical notes, sedation level, mental status, time of discharge, and criteria met.
Billing the monitoring period depends on the payer policy. Work with your payer representatives to confirm whether they accept observation codes, prolonged services codes, or have a specific code for this service.
Step 4: Psychotherapy Add-On (if provided)
If the clinician provides individual psychotherapy during the Spravato session, as many psychiatrists do, capitalizing on the dissociative state’s potential therapeutic window, the appropriate add-on code (90833, 90836, or 90838) can be appended to the E/M code. Document the specific psychotherapeutic technique used, therapeutic content addressed, and the time spent in psychotherapy (distinct from assessment and monitoring time).
Managing Spravato Claim Denials
Spravato denials fall into predictable categories. Here’s how to address each:
- Insufficient prior authorization documentation: Resubmit with complete antidepressant trial history and updated PHQ-9/MADRS scores
- Non-covered diagnosis code: Verify the ICD-10 code matches the approved PA indication exactly (TRD vs. MDSI have different requirements)
- REMS documentation missing: Submit provider and facility REMS certification confirmations
- Incorrect HCPCS code: Confirm the code with your specific MAC or commercial payer; code preferences vary
- Missing NDC: Add the Spravato NDC to the drug billing line item
- Monitoring period not covered: Escalate to payer medical director review; provide FDA REMS documentation mandating monitoring.
Spravato Access Programs for Underinsured Patients
For patients whose insurance does not cover Spravato or who cannot afford cost-sharing:
- Janssen CarePath Savings Program: Provides co-pay assistance for eligible commercially insured patients
- Janssen Patient Assistance Program: Free drug for qualifying uninsured or underinsured patients
- 340B Drug Pricing Program: Eligible healthcare entities can access Spravato at a significantly reduced acquisition cost
- State mental health parity appeals: If a commercial payer denies coverage inconsistent with medical/surgical benefit coverage, file a parity complaint with your state insurance commissioner
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Frequently Asked Questions
Which NDC code goes on Spravato claims?
Use NDC 50458-0028-02 for 28 mg Spravato nasal spray. Bill two units for the standard 56 mg dose; always attach invoice proof for payers requiring drug cost validation.
Can PMHNPs bill Spravato under a physician NPI?
Yes, via Medicare “incident to” rules if the physician establishes a plan and supervises. Reimburses at 100% MPFS versus 85% under PMHNP NPI, boosting revenue significantly.
How long does Spravato PA approval typically take?
Commercial payers average 3-7 days with complete packets; Medicare Advantage 5-10 days. Include PHQ-9 scores and antidepressant failure details to accelerate reviews effectively.
What if the payer rejects G2082 for the Spravato drug?
Switch to S0013 (56 units for 56 mg) or J3490 with documentation. Appeal with REMS certification and FDA label proving medical necessity for coverage.
Does 340B pricing apply to Spravato buy-and-bill?
Yes, eligible REMS-certified facilities access discounted rates, reducing acquisition to ~$200/dose. Bill payers’ full rate while retaining 340B savings for profit margins.