Spravato (Esketamine) Billing: Codes, REMS, Prior Authorization and Buy-and-Bill

Spravato (esketamine nasal spray) is billed as a supervised treatment visit, with the drug either bought and billed by the practice or supplied by a specialty pharmacy. For Medicare, the visit and drug are billed with G2082 (up to 56 mg) or G2083 (more than 56 mg); commercial payers set their own rules. Every payer we have seen requires prior authorization, and the practice must be certified under the Spravato REMS program.

Spravato is one of the highest-value services a psychiatry practice can offer, and one of the easiest to lose money on through missing authorizations, the wrong drug-billing model or observation time that is not documented.

Before the first treatment

1. REMS certification. The treatment site must be certified under the Spravato REMS, and patients are enrolled in the REMS before their first dose.
2. Prior authorization. Payers typically require a diagnosis of treatment-resistant depression (often defined as failed trials of at least two antidepressants at adequate dose and duration) or major depressive disorder with suicidal thoughts or actions, plus current oral antidepressant use where required. Criteria differ by plan.
3. Choose the drug model for this payer: buy-and-bill or specialty pharmacy. Some payers require one model.
4. Verify benefits for both the visit and the drug. They can fall under different benefits (medical vs pharmacy), with different cost sharing.

Buy-and-bill vs specialty pharmacy

	Buy-and-bill	Specialty pharmacy
Who buys the drug	The practice	The pharmacy, for a specific patient
What the practice bills	The treatment visit and the drug	The treatment visit and observation only
Cash flow	Practice pays for the drug before it is reimbursed	No drug cost for the practice
Risk	Denied drug claims are a direct loss	Delays if the shipment is late

Codes by payer type

Payer type	How it is usually billed
Medicare	G2082 (up to 56 mg) or G2083 (more than 56 mg): a visit that includes supervised self-administration of esketamine and at least 2 hours of post-dose observation
Commercial	Varies: often an E/M code for the visit, the drug on the medical claim (for example S0013, esketamine per 1 mg, with the number of units) when bought and billed, and sometimes codes for extended observation
Medicaid	Set by each state and its managed care plans

Check each payer’s current Spravato billing policy. Getting the drug units wrong (billing per device instead of per mg, for example) is a common and costly error.

Documentation for each session

• Dose given and the device lot information your REMS process requires
• Pre-dose vital signs and assessment
• Monitoring during the observation period, including blood pressure checks and sedation or dissociation
• Time of administration and time the patient was cleared to leave (at least 2 hours)
• That the patient was counseled not to drive or operate machinery until the next day after a restful sleep, as the labeling advises
• REMS patient monitoring form submitted

Common Spravato denials

Denial	Cause	Fix
No authorization	Treatment started or continued after the authorization lapsed	Track authorized sessions and renewal dates
Drug denied	Wrong billing model for the payer, or wrong units	Confirm the payer’s drug policy before ordering
Visit and drug on the wrong benefit	Medical vs pharmacy benefit confusion	Verify both benefits before the first session
Frequency	Sessions billed more often than the approved schedule	Follow the induction and maintenance schedule in the authorization

Osmind and other psychiatry EHRs

Many interventional psychiatry practices run Spravato on Osmind or similar systems. See our page for Osmind practices, and our TMS billing guide for the other common interventional treatment.

Spravato labeling, REMS requirements and payer policies change. We check current requirements and each payer’s policy before submission. Our psychiatry billing team handles Spravato authorizations and claims.

Frequently asked questions