Guide to: Esketamine Clinics

Comprehensive Billing & Reimbursement for Wisconsin Critical Access Hospitals

🚀 Mission Briefing: Key Takeaways

🎯Use Specific Codes

Bill with HCPCS codes G2082/G2083. These are your all-in-one, bundled codes that include the drug, administration, and observation for most payers.

✅Pre-Authorization is Universal

All major Wisconsin payers cover Spravato®, but only with strict prior authorization. Get your documentation in order before starting treatment.

💰CAH Status is a Superpower

Leverage your Critical Access Hospital status for significantly enhanced Medicare reimbursement through Method II billing—a major financial advantage.

🧠 Visual Overview: The Mind Map

This mind map provides a complete visual summary of the billing, coding, and reimbursement process. Click the image to view the full-resolution version.

A mind map summarizing the billing and reimbursement guide for Esketamine clinics

🧾 Billing and CPT/HCPCS Codes

Using the correct codes is critical for proper reimbursement. These codes are specific to Spravato® administration and include multiple components of the service.

Payer Guideline Code Full Description
Medicare & Most Payers G2082 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician...and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
Medicare & Most Payers G2083 Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician...and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation.
Some Commercial Payers S0013 Esketamine, nasal spray, 1 mg. This code is for the drug only and is billed per milligram.
Some Commercial Payers 99212-99215 An established patient E/M code may be used for administration/monitoring if the drug is sourced separately (e.g., from a specialty pharmacy).

Important Note: The G-codes (G2082/G2083) are considered "bundled" payments. It is improper to bill a separate E/M code on the same day unless a significant, separately identifiable service is performed and documented correctly.

🗺️ Payer Coverage Landscape in Wisconsin

Universal Requirements for All Payers

Before any claim is paid, you must meet these criteria:

  • REMS Certification: Your facility must be certified through the Spravato® Risk Evaluation and Mitigation Strategy (REMS) program.
  • Strict Prior Authorization: This is always required and must document:
    • A diagnosis of Major Depressive Disorder (MDD).
    • Failure of adequate trials of at least two different oral antidepressants.
    • The patient will continue taking an oral antidepressant concurrently.
    • Use of a validated depression scale (e.g., PHQ-9) to establish a baseline.

Payer-Specific Policies

Medicare (NGS)

Recognizes codes G2082 & G2083. Coverage is outlined in their specific Billing and Coding Article. Source: NGS Article A59250

WI Medicaid

Coverage for Spravato® is managed by individual Managed Care Organizations (MCOs). You must verify the policy for each patient's MCO.

Anthem BCBS

Has a specific clinical guideline for Spravato® (CC-0086) and recognizes all related codes. Source: Clinical Guideline

Dean Health Plan

Covers Spravato® with prior authorization and requires documented failure of at least two previous antidepressant trials.

UnitedHealthcare

Covers under commercial and Medicare Advantage plans. Policy may require billing with E/M codes instead of G-codes; this must be clarified during authorization.

Humana

Policy clearly states that G2082 and G2083 are the appropriate bundled codes to use for the drug, administration, and observation.

Quartz

A specific coverage policy is not publicly available, meaning a prior authorization request with full clinical documentation is necessary to determine coverage.

⭐ The Critical Access Hospital (CAH) Advantage

For Medicare patients, CAHs that have elected Method II billing have a significant reimbursement advantage over other facility types.

How Method II Billing Works for Spravato®

When you submit a claim on a UB-04 form, the payment is split into two powerful streams:

  • Facility Component (101% of Cost): Your CAH gets reimbursed 101% of its reasonable costs for the expensive Spravato® drug vials and the staff time for the 2-hour observation. This is settled via your annual Medicare cost report.
  • Professional Component (115% of Fee): The psychiatrist's professional service of evaluation, management, and supervision is paid separately at 115% of the standard Medicare Physician Fee Schedule amount.

Method II in Action:

A Medicare patient receives an 84mg dose, billed with HCPCS G2083.

  • Part 1 (Facility Payment): Your CAH is paid 101% of the cost for the Spravato® vials and the nurse's time for monitoring.
  • Part 2 (Professional Payment): Your CAH is paid 115% of the established Medicare fee for the physician's work component within that G2083 code.

The bottom line: This dual structure provides higher, more cost-reflective reimbursement, making the service more sustainable for a CAH.

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