SPRAVATO Billing Guide

SPRAVATO Overview

SPRAVATO (esketamine nasal spray) is FDA-approved for treatment-resistant depression (TRD) and major depressive disorder (MDD) with suicidal ideation. Unlike IV ketamine, SPRAVATO is covered by many insurance plans, but billing requires navigating a complex REMS program and specific coding requirements.

Key Differences from IV Ketamine

Aspect	SPRAVATO	IV Ketamine
FDA Approval	Yes (TRD, MDD with SI)	Off-label for depression
Insurance Coverage	Often covered	Usually cash-pay
Administration	Nasal spray, self-administered	IV infusion by provider
Monitoring	2+ hours post-administration	During infusion
REMS	Required	Not applicable

REMS Certification Requirements

SPRAVATO requires enrollment in the REMS (Risk Evaluation and Mitigation Strategy) program before you can prescribe or administer.

Healthcare Setting Requirements

• Complete REMS enrollment via the SPRAVATO portal
• Staff must be certified (prescribers and healthcare staff who monitor)
• Patient must be enrolled and complete Patient Enrollment Form
• Document compliance with monitoring requirements
• Drug cannot leave the healthcare setting

Per-Visit REMS Compliance

1. Verify patient hasn't eaten for 2 hours, drunk liquids for 30 minutes
2. Confirm patient has arranged transportation (cannot drive day of treatment)
3. Monitor blood pressure before dosing
4. Patient self-administers under supervision
5. Monitor for 2+ hours post-administration
6. Document all REMS requirements were met
7. Complete the PDSS (Patient Status Sheet) form

Billing Codes

Drug Codes (HCPCS)

Code	Description	Dose
J3305	SPRAVATO (esketamine) nasal spray	1 mg

Important: J3305 is billed per 1mg. A 56mg dose = 56 units. An 84mg dose = 84 units.

Administration & Observation Codes (CPT)

Code	Description
90899	Unlisted psychiatric service (sometimes used)
99211-99215	E/M office visit (for assessment)
96372	Therapeutic injection (not always applicable)

Place of Service

Use POS 11 (Office) for outpatient administration. SPRAVATO must be administered in a certified healthcare setting.

Common Modifier Usage

• JW - Drug amount discarded (if applicable)
• Check payer-specific modifier requirements

Prior Authorization

Most payers require prior authorization for SPRAVATO. Common requirements include:

Medical Necessity Documentation

• Diagnosis of TRD (failed 2+ antidepressants) or MDD with suicidal ideation
• Documentation of previous treatments and failures
• Current PHQ-9 or MADRS scores
• Treatment plan with frequency and duration
• REMS enrollment confirmation

Common Payer Requirements

• United Healthcare: Step therapy documentation, PA required
• Aetna: Must meet TRD criteria, PA required
• BCBS: Varies by state, typically PA required
• Medicare: Covered under Part D, check specific plan

Documentation Requirements

Proper documentation is essential for billing compliance and REMS adherence:

Each Treatment Session Must Document

• Pre-treatment blood pressure
• Dose administered (56mg or 84mg)
• Time of administration
• Monitoring observations (typically every 30 min)
• Post-treatment blood pressure (before discharge)
• Dissociative symptoms if any
• Patient discharged with transportation (documented)
• PDSS form completed

EHR Template Recommendations

Your EHR should have templates that capture:

• REMS compliance checklist (built into workflow)
• Vital signs table with timestamps
• Dissociation scale documentation
• Patient status at discharge
• Next appointment scheduling

Software with SPRAVATO Support

The following EHR systems have documented SPRAVATO billing or workflow support:

• Osmind - Psychiatry-tailored EHR and billing platform serving 800+ independent mental health practices with s...

Key EHR Features for SPRAVATO

• REMS compliance tracking built into workflow
• Vital signs documentation with timestamps
• Prior authorization tracking
• Buy-and-bill inventory management
• J-code billing support
• Automated PDSS form generation