Supervision Requirements for TMS
Why Supervision Is the Most Misunderstood Topic in TMS
In the day-to-day operation of a TMS clinic, almost no topic causes more confusion than supervision.
The reason is that “supervision” in TMS doesn’t mean one thing. It means at least three things stacked on top of each other: a Medicare framework that defines how physically present a supervising provider must be, a state-by-state scope-of-practice framework that defines who can supervise in the first place, and a payer-by-payer set of policies that may layer additional requirements on top of both.
Get any one of these wrong and the consequences range from denied claims to retroactive payer audits to license discipline for your medical director. Get all three right, and you’ve built one of the most defensible service lines in outpatient psychiatry.
This post unpacks each layer, walks through who can do what under the standard CPT codes (90867, 90868, 90869), and lays out the practical compliance steps every TMS clinic should have in place before treating their first patient.
Layer 1: The Medicare Supervision Framework
Medicare defines three levels of physician supervision for outpatient services. Even if you’re a fully cash-pay clinic, this framework matters—commercial payers routinely adopt Medicare’s supervision standards by reference, and state medical boards often look to it as the baseline for what “appropriate supervision” means.
General Supervision
The procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the procedure. This is the lowest tier and almost never applies to TMS.
Direct Supervision
The physician (or other qualified supervising practitioner) must be immediately available to furnish assistance and direction throughout the procedure. The supervising provider does not need to be in the same room as the patient, but they must be on-site and able to respond immediately. This is the standard that applies to most TMS treatment delivery.
Note: During the COVID-19 public health emergency, CMS temporarily allowed “direct supervision” to be satisfied by real-time audio/video presence rather than physical presence. CMS has extended that flexibility through 2026 for many services, including those rendered “incident-to,” which includes TMS. Whether it continues to apply to TMS in any given year, and under any given payer’s policy, should always be verified before relying on it.
Personal Supervision
The physician must be in attendance in the room during the procedure. This is the strictest tier.
Layer 2: State Scope-of-Practice Rules
Medicare’s framework tells you how present a supervising provider must be. State scope-of-practice law tells you who that provider can be in the first place—and the answer varies dramatically by state.
In every state, an MD or DO with appropriate training can serve as the supervising provider for TMS. The variation is in whether non-physician practitioners (NPPs)—specifically nurse practitioners and physician assistants—can also supervise, and under what conditions.
Nurse Practitioners (NPs)
Full Practice Authority states (e.g., Arizona, Colorado, New Mexico, Oregon, Washington, Iowa, Maine, Minnesota, Vermont, New Hampshire, Hawaii, Alaska, Montana, North Dakota, South Dakota, and others): NPs may independently evaluate patients, prescribe TMS, and supervise its delivery, often without a collaborative agreement.
Reduced or Restricted Practice states (e.g., California, Texas, Florida, North Carolina, Michigan, Ohio, Pennsylvania, Georgia, Tennessee): NPs typically need a collaborative agreement with a supervising physician, and the scope of what they can do under that agreement varies. Whether an NP can serve as the supervising provider for TMS specifically is often a payer-policy question on top of a scope-of-practice question.
Physician Assistants (PAs)
PAs always practice under some form of physician supervision, though the rigor of that supervision varies by state. In most states, a PA with appropriate training can perform motor threshold determinations and supervise treatment delivery, but the supervising physician must remain available—either on-site, by phone, or by some other defined mechanism—per state requirements.
Technicians (whether MAs, RNs, LPNs, or dedicated TMS operators) are not independently licensed to deliver medical care. They operate the device under the direct supervision of a credentialed provider. State law generally does not specify a minimum educational requirement for TMS technicians, but payers and accreditation bodies routinely require manufacturer training plus a recognized TMS certification—which is exactly the gap that programs like Solstice Training Institute’s TMS Technician Certification are designed to fill.
Layer 3: Payer-Specific Supervision Policies
Once you’ve worked through the Medicare framework and your state’s scope-of-practice rules, individual payer policies layer in additional requirements. These are the policies that most often cause clean-on-paper claims to come back denied.
Medicare
Medicare covers TMS for treatment-resistant major depressive disorder under Local Coverage Determinations (LCDs) that vary slightly by Medicare Administrative Contractor. Most LCDs require:
TMS to be ordered by, and furnished under the direct supervision of, a psychiatrist (or in some LCDs, a physician with documented experience in TMS). However, it’s important to note that CMS relaxed its direct supervision requirements permanently in 2026, which may allow for TMS services to be treated during general supervision.
The initial treatment session (90867) to be performed personally by the supervising provider.
Subsequent treatment sessions (90868) to be furnished under direct supervision, meaning the provider is on-site and immediately available.
Documentation of the supervising provider’s training (such as a copy of their Solstice Training Institute certification), the patient’s prior treatment failures, and ongoing symptom monitoring with validated scales (PHQ-9, BDI, HAM-D, MADRS, or similar).
Commercial Payers
Most large commercial payers (Aetna, Cigna, UnitedHealthcare, the Blues) follow a similar pattern: physician (or in some cases, NPP) supervision, prior authorization, validated outcome measures, and documentation of failed pharmacotherapy. The differences tend to be in the details:
Some Blue Cross plans require the attending physician to personally perform the first treatment, including the initial cortical mapping and motor threshold determination.
Some plans require the supervising provider to be physically on-site during every treatment session, regardless of CMS flexibilities.
Some plans require the technician operating the device to hold a recognized TMS certification—one of the reasons clinics whose technicians are certified through a credible program tend to get authorized faster.
Some plans contract supervision and authorization decisions out to managed care organizations (e.g., Lucet, NIA/Magellan), each with their own additional requirements.
Medicaid
State Medicaid coverage of TMS varies widely. Some state Medicaid programs cover TMS as a routine benefit (California’s Medi-Cal added it as a covered benefit for patients 15 and older effective August 2024). Others mirror Medicare LCDs. Others don’t cover TMS at all. Supervision requirements typically follow whichever framework the state Medicaid program adopts.
Supervision by CPT Code: Who Has To Do What
Putting all three layers together, here’s how supervision typically maps to the three TMS CPT codes:
CPT 90867 — Initial Treatment Planning Session
This code covers the initial cortical mapping, motor threshold determination, and first treatment session. It is the highest-acuity component of the TMS course and the one with the strictest supervision requirements:
Many commercial payers request for this session to be overseen by the attending provider rather than delegated to a technician.
Billed once per treatment course.
CPT 90868 — Subsequent Delivery (No Re-Mapping)
This is the daily treatment session that constitutes the bulk of a course. Supervision rules here are the most operationally consequential, because they determine how many providers you need on-site each day:
Almost universally requires general supervision: the supervising provider on-site and immediately available, but not necessarily in the room.
The actual treatment delivery is typically performed by a trained TMS technician.
The supervising provider must be available to respond to seizures, vasovagal events, or other adverse events.
Billed once per session, never on the same day as 90869.
CPT 90869 — Subsequent Delivery with Re-Mapping
This code covers a subsequent session in which the motor threshold is re-determined. Re-mapping is a clinical judgment call, typically made when a patient’s response is unexpected or their tolerance changes:
Requires the supervising provider to personally perform the re-mapping, just like the initial 90867 session.
After re-mapping, the treatment portion may be delivered by a technician under direct supervision.
Cannot be billed on the same day as 90867 or 90868.
Practical Steps for Building a Compliant Supervision Model
Whatever your clinic size and provider mix, the following steps form a defensible supervision program:
1. Document Your Supervising Provider’s Credentials
Maintain on-file evidence of your supervising provider’s state license, DEA registration, board certification, and certification from Solstice Training Institute. Most payers require this documentation as part of credentialing, and audit teams will ask for training evidence for all providers and technicians on record.
2. Maintain Written Supervision Protocols
Create and regularly update SOPs that document who supervises, how supervision is structured, how the supervising provider is reachable during sessions, and what happens during adverse events. These SOPs should be signed by the medical director and reviewed at least annually.
3. Train Your Technicians and Document That Training
Technicians should be trained on device operation, patient screening, recognizing adverse events, and emergency protocols. Maintain records of completed training and certifications. Both payers and accreditation bodies will ask for these.
4. Build Supervision Into Your EMR
Every treatment note should include the supervising provider’s name, the supervising provider’s presence at the time of treatment, and the technician administering the session. This isn’t a paperwork formality—it’s the only contemporaneous evidence you have if a payer audits the claim two years later.
5. Verify Payer-Specific Requirements at Credentialing
Don’t assume one payer’s policy is identical to another’s. As part of credentialing with each payer, pull the relevant medical policy or LCD and confirm: who can supervise, what level of supervision is required for each CPT code, and whether the technician must hold a specific certification. Build the answers into your SOPs.
6. Plan for Coverage
Your supervising provider will eventually take vacation, get sick, or take parental leave. Build a credentialed coverage roster ahead of time so the clinic can keep treating patients without falling out of compliance the moment your medical director steps away.
Key Takeaways for TMS Clinic Operators
Supervision is not a side issue in TMS—it sits at the center of the clinic’s clinical, regulatory, and financial integrity. Get the framework right and almost every other compliance question becomes easier to answer.
Medicare’s supervision tiers (general, direct, personal) define how present the supervising provider must be. Direct supervision is the standard for most TMS treatment delivery; personal supervision is the standard for initial mapping and re-mapping.
State scope-of-practice law determines who can serve as the supervising provider. MDs/DOs are universally permitted; NPs and PAs can supervise in many states but with state-specific limits.
Payer policies layer on top of state and federal frameworks. Always verify the specifics of each contracted payer’s TMS coverage policy at credentialing.
Documentation is the single most important compliance tool. Every treatment note should reflect who supervised and who administered the session, every time.
Technician certification matters. Many payers require—and most accreditation bodies expect—that TMS technicians hold a recognized certification beyond manufacturer training.
A TMS clinic that takes supervision seriously protects its patients, its revenue, and its medical director’s license. A clinic that doesn’t will eventually pay for that gap one way or another.
Ready to build a compliant TMS supervision program? Solstice Training Institute, A Public Benefit Corporation offers tiered TMS certification programs for technicians, providers, and clinic owners that cover supervision frameworks, documentation standards, and payer-specific compliance in detail. Enroll today at solsticetraining.org.
