Electroconvulsive Therapy sits in a stranger corner of behavioral health billing than almost anything else in psychiatry. It’s a single, tightly defined CPT code — 90870 — that somehow touches three separate billing worlds at once: the psychiatrist performing the procedure, the anesthesiologist or CRNA managing sedation, and the hospital or facility providing the room, the equipment, and the recovery care. Miss the coordination between those three, and you don’t just lose one claim — you lose it three times over, for every single treatment in the series.
ECT has also just been through one of the more significant reimbursement changes in recent psychiatric billing history. Medicare’s inpatient per-treatment payment for ECT jumped from $385.58 to roughly $661 starting in federal fiscal year 2025 — a 72% increase tied directly to updated hospital cost data for CPT code 90870. That’s the kind of change that makes accurate ECT billing worth a much closer look than it may have gotten in years past.
What is ECT Billing ?
ECT billing is the process of submitting and managing insurance claims for Electroconvulsive Therapy services. It involves accurate procedure coding, medical necessity documentation, treatment records, authorization requirements, insurance verification, and compliance with payer-specific guidelines.
At House of Outsourcing, we provide specialized ECT billing services to help practices manage claims accurately and reduce avoidable reimbursement issues. Our team supports claim submission, denial management, payment follow-up, and A/R management to maintain an efficient revenue cycle.
Why Your Practice ECT Billing Doesn’t Behave Like the Rest of Behavioral Health
A few things set ECT apart from psychotherapy, medication management, or even TMS billing:
- It’s a three-party claim, not a one-party claim: The physician performing ECT, the anesthesia provider, and the facility itself typically each submit separate claims for the same treatment date.
- It requires general anesthesia every time: That alone pulls ECT into anesthesia billing rules, NCCI bundling edits, and coordination between two entirely different billing departments.
- The regulatory and consent requirements are unusually heavy: Many states have ECT-specific informed consent statutes — not just general procedural consent — with additional protections for minors and involuntary patients.
- Payment methodology depends heavily on setting: Inpatient psychiatric facility (IPF) treatments are paid through a per-treatment add-on under the IPF Prospective Payment System, while hospital outpatient department treatments fall under the Outpatient Prospective Payment System (OPPS) — two different payment structures for the same CPT code.
- The reimbursement landscape just shifted meaningfully: CMS’s FY 2025 IPF PPS final rule raised the ECT per-treatment payment substantially, based on updated OPPS geometric mean cost data — a change worth flagging to any practice that hasn’t revisited its ECT reimbursement assumptions recently.
Where Your ECT Practice Revenue Commonly Gets Lost
Your ECT practice revenue can be lost through coding errors, incomplete documentation, authorization issues, incorrect claim details, and missed payer requirements. Identifying these gaps early can help prevent denials, reduce payment delays, and protect expected reimbursement.
| ECT Billing Area | What Typically Goes Wrong | Revenue Impact |
| Professional vs. anesthesia billing | Confusion over who bills 90870 vs. 00104, or duplicate billing by the same provider | Denials, overpayment recoupment |
| Facility claims | Outpatient facility claim submitted without matching the physician’s claim details | Payment delays, mismatched documentation |
| Setting classification | Inpatient vs. outpatient payment methodology confused | Incorrect payment amount, audit risk |
| Consent documentation | State-specific ECT consent requirements not fully met before treatment | Compliance exposure independent of reimbursement |
| Series tracking | Treatment count and frequency not documented consistently across a series | Medical necessity denials on later treatments |
| Maintenance ECT | Ongoing continuation treatments billed without updated necessity documentation | Denial after an initial series is otherwise well-supported |
Who’s Involved in Billing a Single ECT Treatment?
Every ECT session involves more coordinated roles than most psychiatric services, and each one has its own billing footprint.
- Psychiatrist (or other qualified physician) performing ECT: Bills the professional component under 90870 — the procedure itself, including the necessary monitoring built into the code.
- Anesthesiologist or CRNA: Administers general anesthesia and a muscle relaxant, billed separately under the appropriate anesthesia code (commonly 00104, the anesthesia code that crosswalks to ECT).
- Facility (hospital or inpatient psychiatric unit): Bills its own claim for the room, equipment, nursing, recovery monitoring, and supplies — under IPF PPS for inpatient care or OPPS for hospital outpatient departments.
- Referring/treating psychiatrist (if different from the one performing ECT): Often responsible for documenting the treatment-resistance history that establishes medical necessity for the whole series.
- Psychiatric nursing staff: Support pre- and post-treatment monitoring, which factors into facility-side documentation even though it isn’t separately billed by the nurse.
| Role | What They Bill | Claim Type | Billing Consideration |
| Performing psychiatrist | 90870 | Professional (CMS-1500) | Cannot also bill for anesthesia if performed personally — one or the other, not both |
| Anesthesiologist/CRNA | 00104 (or payer-specific equivalent) | Professional (CMS-1500) | Billed on a separate claim from the psychiatrist’s 90870 |
| Hospital/facility | Facility charges under IPF PPS or OPPS | Institutional (UB-04) | Payment methodology depends on inpatient vs. outpatient status |
| Referring psychiatrist | May bill related E/M separately if distinct from ECT day | Professional (CMS-1500) | Documentation must show the service is separate from the ECT procedure itself |
The Core ECT Code: What 90870 Actually Covers
CPT 90870 describes electroconvulsive therapy, including the necessary monitoring that accompanies the procedure. It’s reported once per treatment session — not once per series — so a typical acute course of six to twelve treatments generates that many separate 90870 claims, each tied to its own date of service. A few coding rules matter here:
- 90870 should only be reported when a formal ECT procedure is actually performed — not for pre-treatment psychiatric evaluations or post-treatment follow-up visits, which are billed under their own applicable codes.
- Anesthesia is billed separately, not bundled into 90870, except in the specific scenario where the same physician personally performs both the ECT procedure and administers the anesthesia. In that narrow case, NCCI edits generally prevent billing both codes together, since the RVUs for 90870 are structured to reflect that overlap.
- Same-day E/M services unrelated to the ECT procedure itself — for instance, a distinct medical issue the psychiatrist addresses that day — can potentially be billed separately with appropriate documentation and modifier 25, following the same “significant, separately identifiable service” standard used across the rest of psychiatric billing.
Anesthesia Billing for ECT: Keeping the Professional and Anesthesia Claims Straight
Because ECT always requires general anesthesia and a muscle relaxant, the anesthesia billing side deserves its own attention rather than being treated as an afterthought.
In the standard scenario — where a psychiatrist performs the ECT and a separate anesthesiologist or CRNA manages sedation — each provider bills independently:
- The psychiatrist bills 90870 on their own professional claim.
- The anesthesia provider bills the applicable anesthesia code (commonly the code that crosswalks to ECT under the ASA relative value guide) on a separate professional claim, often with anesthesia-specific time units and modifiers reflecting the provider type (e.g., personally performed, medically directed, or medically supervised).
Where practices run into trouble is when the same physician bills for both roles — this is uncommon, but when it happens, National Correct Coding Initiative edits treat the anesthesia component as bundled into 90870 and won’t allow separate payment for both. It’s also worth confirming with each payer whether they follow AMA CPT guidance or their own bundling logic here, since payer policy on this specific overlap isn’t always identical to NCCI’s default position.
| Scenario | Who Bills What | Documentation Focus | Common Error |
| Separate psychiatrist and anesthesiologist | Psychiatrist bills 90870; anesthesiologist bills anesthesia code separately | Each provider’s own note supports their own service | Facility fails to reconcile both professional claims against the same date of service |
| Same physician performs both roles | Only 90870 is billable; anesthesia is bundled | Note should reflect physician performed both roles personally | Billing both codes separately when NCCI bundles them |
| CRNA-administered anesthesia | CRNA bills under own NPI or per payer/state supervision rules | Supervision level documented per state law | Supervision requirements not verified against state scope-of-practice rules |
Medical Necessity: What Payers Actually Require Before Approving Your ECT Practice Claims
ECT is generally reserved for severe, often treatment-resistant psychiatric presentations, and payer medical policies reflect that. Common medical necessity elements include:
- A diagnosis of severe major depressive disorder (often with psychotic features, catatonia, or high suicide risk), severe bipolar depression or mania, schizophrenia with prominent affective or catatonic features, or catatonia from another cause
- Documentation of prior treatment history — typically failed or poorly tolerated trials of antidepressant or antipsychotic medication, though ECT is also recognized as a first-line option in specific high-acuity situations (e.g., severe suicidality, catatonia, or a need for rapid response that medication trials can’t provide)
- A pre-treatment medical evaluation confirming the patient can safely tolerate general anesthesia
- Ongoing documentation across the series showing clinical response, since a course of ECT is typically reviewed treatment by treatment rather than authorized as a single lump-sum service
- For continuation or maintenance ECT: documentation of an adequate response to the acute series and an ongoing risk of relapse without continued treatment
ICD-10-CM Coding for ECT: Matching the Diagnosis to the Acuity
| Indication | Common ICD-10-CM Codes | Coding Note |
| Severe major depressive disorder, single or recurrent episode | F32.2, F32.3, F33.2, F33.3 | Codes reflecting severe or psychotic-featured episodes are most consistent with ECT’s typical use case |
| Bipolar disorder, severe episodes | F31.2, F31.5, F31.63, F31.64 | Applies to severe manic or depressive episodes with or without psychotic features |
| Schizophrenia and related psychotic disorders | F20.0–F20.9, F25.0–F25.9 | Used when affective or catatonic features drive ECT’s clinical rationale |
| Catatonia | F06.1 (catatonic disorder due to another medical condition) or catatonia associated with the primary psychiatric diagnosis | Documentation should clarify the underlying diagnosis driving the catatonic presentation |
| Postpartum-onset severe depression or psychosis | Coded under the applicable F32/F33/F53 code with postpartum specifiers as appropriate | Acuity and safety concerns often support urgent ECT use in this population |
Inpatient vs. Outpatient ECT: Two Different Payment Systems for the Same Code
This is one of the more consequential distinctions in ECT billing, and it’s easy to overlook if a practice is used to psychiatric services that are billed the same way regardless of setting.
- Inpatient Psychiatric Facility (IPF) treatment: ECT is paid as a per-treatment add-on under the IPF Prospective Payment System. This add-on is layered on top of the facility’s per diem payment rather than billed as a standalone line item the way an outpatient claim would be.
- Hospital Outpatient Department (HOPD) treatment: ECT delivered in an outpatient setting — common for continuation or maintenance treatment, or for patients who don’t require inpatient admission — is paid under OPPS, using its own ambulatory payment classification logic and geometric mean cost data.
Documentation That Supports an ECT Claim
Strong ECT documentation should clearly support medical necessity, the treatment provided, clinical findings, patient response, and relevant treatment details. Complete and consistent records help substantiate the claim, meet payer requirements, and reduce the risk of denials or reimbursement delays.
| Documentation Element | Why It Matters | Common Gap |
| Pre-treatment psychiatric evaluation and diagnosis | Establishes the clinical basis for ECT | Severity/acuity not clearly documented relative to less intensive alternatives |
| Prior treatment history (medications, hospitalizations, response) | Supports medical necessity, especially for non-emergent cases | Summarized too vaguely to satisfy payer review |
| Pre-anesthesia medical clearance | Confirms the patient can safely undergo general anesthesia | Clearance not dated close enough to the treatment series start |
| Treatment-by-treatment progress notes | Shows the series remains medically necessary as it continues | Later treatments in a series documented with minimal updates |
| Seizure duration and treatment parameters | Standard clinical documentation for each ECT session | Parameters recorded inconsistently across the series |
| Anesthesia record | Supports the separate anesthesia claim | Anesthesia note not clearly linked to the same date of service as 90870 |
| Consent documentation | Required both clinically and, in many states, by statute | Consent renewal not documented if the series extends beyond the original authorized scope |
Informed Consent and State Law
ECT carries some of the heaviest informed consent requirements in psychiatric medicine, and in many states, these aren’t just best-practice recommendations — they’re written into law. California, for example, sets out detailed ECT consent requirements under its Welfare and Institutions Code, including written consent requirements, specific disclosures, and additional protections when a patient’s capacity to consent is in question. Ohio’s administrative code similarly defines ECT-specific requirements, including who qualifies as a treating psychiatrist for these purposes. Many states also require:
- A second, independent physician’s evaluation or certification in certain circumstances
- Additional review or court/tribunal-style approval for minors or patients who lack capacity to consent
- Documentation of the number of treatments and duration of the authorized course, since consent is often tied to a defined series rather than an open-ended authorization
- The patient’s ongoing right to withdraw consent at any point in the series, even after treatment has started
HIPAA and Recordkeeping Considerations for ECT
ECT records carry the same HIPAA protections as any other behavioral health documentation, with a few points worth calling out specifically for this service:
- Psychiatric diagnoses, treatment history, and consent documentation are all protected health information, and access should be limited to those with a legitimate treatment, payment, or operations need — consistent with HIPAA’s minimum-necessary standard.
- Coordination across three billing entities (psychiatrist, anesthesia provider, facility) means PHI is being shared across more parties than a typical single-provider claim — each of those relationships should be governed by an appropriate Business Associate Agreement where a third-party billing vendor is involved.
- Some ECT programs operate within, or alongside, substance use disorder treatment programs. Where that overlap exists, records may also fall under 42 CFR Part 2’s more restrictive consent-for-disclosure requirements, which layer on top of standard HIPAA rules and generally require patient-specific consent before sharing records outside the treating program.
- Retention requirements for psychiatric and consent records often extend longer under state law than general HIPAA retention expectations — worth confirming against the specific state’s medical records statute rather than assuming a single national standard applies.
Continuation and Maintenance ECT & Billing an Ongoing Course, Not Just an Acute Series
Many patients who respond well to an acute ECT series continue on a tapering or maintenance schedule to sustain remission — sessions that might occur weekly, then biweekly, then monthly over an extended period. Billing-wise, each of these sessions is still coded as 90870, but the medical necessity documentation needs to evolve along with the clinical picture:
- The chart should clearly document the patient’s response to the acute series that preceded maintenance treatment
- Ongoing sessions need periodic reassessment showing continued clinical benefit or genuine relapse risk without treatment — not just a standing order carried forward indefinitely
- Payers may apply separate frequency or duration limits to maintenance ECT compared to an acute series, so authorization status should be checked specifically for the maintenance phase rather than assumed to carry over automatically
Prior Authorization and Insurance Verification for ECT
| Verification Question | Why It Matters | Risk If Skipped |
| Does this payer require prior authorization for an ECT series? | Requirements vary by payer and by inpatient vs. outpatient setting | Series started without approval, risking non-payment for later treatments |
| Is there a maximum number of treatments authorized per series? | Some payers cap the initial authorization and require reauthorization | Treatments beyond the authorized count go unpaid |
| Does the plan separately authorize maintenance/continuation ECT? | Maintenance often requires its own authorization distinct from the acute series | Continuation treatments denied despite acute series being covered |
| How does this payer handle the professional/anesthesia/facility split? | Some payers bundle differently than Medicare’s standard structure | Unexpected denials on one of the three claim types |
| Are there state Medicaid-specific limits on ECT treatments per year? | State Medicaid programs frequently cap annual ECT utilization | Treatments beyond the state limit are non-billable |
Why Your ECT Claims Get Denied
Your ECT claims can be denied due to incorrect procedure coding, insufficient medical necessity documentation, missing authorization, incomplete treatment records, or payer-specific billing requirements. Reviewing these details before submission can help reduce avoidable denials and prevent reimbursement delays.
| Denial Reason | Likely Cause | Prevention |
| Duplicate anesthesia billing | Same physician bills both 90870 and an anesthesia code for the same encounter | Confirm NCCI bundling status before submitting when the same provider performs both roles |
| Medical necessity denial | Diagnosis and treatment history documentation don’t reflect ECT-level acuity | Ensure severity, prior treatment failure, or urgency is explicit in the note |
| Setting mismatch | Claim submitted under the wrong payment methodology (inpatient vs. outpatient) | Confirm patient status and route the claim through the correct payment system |
| Authorization lapse mid-series | Initial authorization covered fewer treatments than the series required | Track authorized treatment counts against the actual number delivered |
| Consent documentation gaps | State-specific consent requirements not fully documented | Use a jurisdiction-specific consent process, reviewed against current state law |
| Facility/professional claim mismatch | Facility and physician claims report inconsistent dates or details | Reconcile facility and professional billing for each treatment date before submission |
| Missing maintenance-phase justification | Continuation ECT billed without updated necessity documentation | Reassess and document necessity at defined intervals throughout maintenance treatment |
Credentialing for Your ECT Practice
Credentialing for your ECT practice involves enrolling providers with insurance payers, verifying professional credentials, maintaining accurate documentation, and meeting payer-specific enrollment requirements. Proper credentialing helps prevent enrollment gaps, claim denials, billing interruptions, and delays in reimbursement.
| Credentialing Step | Responsible Party | Common Delay | Impact |
| Psychiatrist privileging for ECT | Hospital medical staff office + credentialing team | Facility-specific privileging requirements beyond standard psychiatric credentialing | Provider can’t perform or bill ECT until privileges are granted |
| Anesthesiologist/CRNA credentialing | Hospital credentialing + payer enrollment | Coordinating anesthesia group enrollment separately from the psychiatry practice | Anesthesia claims delayed even when the ECT claim is clean |
| Facility licensure and accreditation | Facility administration | State-specific ECT program licensure or accreditation standards | Facility claims denied if licensure lapses |
| Medicare/Medicaid enrollment | Credentialing team | IPF-specific enrollment steps distinct from general hospital enrollment | Delayed billing for a newly launched ECT program |
| CAQH and commercial payer enrollment | Provider + credentialing team | Attestation lapses, especially for psychiatrists newly credentialed for a procedural privilege | Commercial claims pend for credentialing verification |
Place of Service Considerations
ECT is almost always delivered in a hospital setting given the anesthesia requirement, but the specific place-of-service designation still matters for claims routing:
| Setting | Typical POS | Payment System | What to Verify |
| Inpatient psychiatric facility | POS 21 (inpatient hospital) | IPF PPS per-treatment add-on | Patient’s inpatient status is accurately reflected across all three claim types |
| Hospital outpatient department | POS 19 or 22 (off-campus/on-campus outpatient hospital) | OPPS | Facility and professional claims both reflect outpatient status consistently |
| Ambulatory surgical center | Rarely used for ECT currently | Generally not separately recognized for ECT under Medicare’s ASC covered procedures list | Confirm payer-specific policy before scheduling ECT at a non-hospital site |
ECT Across Different Practice Settings
ECT billing requirements can vary across hospitals, outpatient centers, psychiatric facilities, and other practice settings. Differences in services, documentation, payer policies, coding requirements, and reimbursement processes make it important to use a billing workflow that fits each setting.
| Practice Setting | Typical Structure | Billing Complexity | Revenue-Cycle Focus |
| Freestanding inpatient psychiatric hospital | Acute ECT series delivered during inpatient admission | High — IPF PPS add-on payment logic layered on top of per diem billing | Accurate treatment-count tracking within each admission |
| General hospital with psychiatric unit | ECT delivered inpatient, with outpatient continuation after discharge | Highest — requires coordinating both IPF PPS and OPPS billing for the same patient over time | Smooth handoff from inpatient to outpatient billing workflows |
| Academic medical center | Higher-acuity cases, closer coordination between psychiatry and anesthesia departments | High — multiple departments billing independently for the same patient | Strong reconciliation process across professional and facility claims |
| Outpatient maintenance ECT program | Tapering or long-term maintenance sessions after an acute series elsewhere | Moderate — fewer parties involved per visit, but longer-term documentation demands | Periodic medical necessity reassessment built into the workflow |
Is Your ECT Program Capturing Every Dollar Across Three Separate Claims?
ECT billing asks a practice to get three moving pieces right at once — the professional claim, the anesthesia claim, and the facility claim — for every single treatment in a series that can run for weeks or months. Add state-specific consent law, a payment methodology that changes depending on inpatient or outpatient setting, and a reimbursement landscape that just shifted significantly for 2025, and it’s easy to see how revenue slips through gaps that aren’t obvious from any single claim.
House of Outsourcing supports psychiatric practices and facilities across the full ECT revenue cycle:
| Billing Challenge | What It Costs the Practice | How House of Outsourcing Helps |
| Eligibility and benefits verification | Series started before confirming coverage or authorization limits | Payer-specific verification, including inpatient vs. outpatient distinctions |
| Prior authorization | Later treatments in a series denied when authorization runs out | Authorization tracked against the full planned course, including maintenance phases |
| ECT-specific coding (90870, anesthesia coordination) | Duplicate billing or missed NCCI bundling issues | Coders trained specifically on the professional/anesthesia/facility split |
| Charge entry and claims submission | Mismatched claims across three billing entities for the same treatment date | Reconciliation workflows built around ECT’s multi-party billing structure |
| Payment posting | Setting-based underpayments going unnoticed across a long treatment course | Payment posting that accounts for IPF PPS vs. OPPS payment differences |
| Denial management | Consent-related and medical-necessity denials left unappealed | Targeted appeals backed by documentation and consent-compliance review |
| A/R follow-up | Aging claims tied up across multiple billing entities | Dedicated follow-up spanning professional, anesthesia, and facility claims |
| Credentialing and payer enrollment | Delayed program launch due to ECT-specific privileging steps | Credentialing tracked for psychiatrists, anesthesia providers, and the facility itself |
| Reporting and revenue-cycle analysis | No visibility into where an ECT program is losing revenue across its three claim types | Treatment-series-level reporting that surfaces denial patterns early |
