The New SPRAVATO® J Code (J0013): What Clinicians Need to Know About the 2026 Transition

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One clinician noticed their Spravato reimbursement dropped $90 overnight in January. The culprit? A billing code change that caught many practices off guard.

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If you offer Spravato and haven't heard about the S0013 to J0013 transition, you're not alone. CMS made the switch effective January 1, 2026, but the rollout has been messy. Payer systems weren't updated in time. Prior authorizations are being handled inconsistently. And some practices are already seeing claim rejections or unexpected reimbursement changes.

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We've been tracking what clinicians are experiencing in the Osmind community, and this post pulls together what we know so far. Consider it a living document. We're learning alongside you.

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What you'll find here:

• What the S0013 → J0013 switch actually means
• How different payers are handling the transition (with real examples)
• Which prior authorizations are still valid and which need to be redone
• Action steps to protect your practice from claim denials
• What we're still figuring out together

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CMS discontinued HCPCS code S0013 and replaced it with J0013

CMS discontinued HCPCS code S0013 and replaced it with J0013 (esketamine, nasal spray, 1 mg) as part of its 2026 HCPCS Level II update.[^1]

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Same drug. Same unit. New code.

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Medicare G-codes remain unchanged. If you're billing Medicare, you'll continue using G2082 (56mg) and G2083 (84mg). The 2026 CMS fee schedule sets G2082 at $906.51 and G2083 at $1,289.82.[^5]

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Here's a quick reference for which Spravato code to use:

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S Code vs. J Code: Why Does This Matter?

You might be wondering why this matters beyond updating your billing system. There are a few reasons worth understanding.

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S-codes are intended for commercial payer use only. They're not payable when billed directly to Medicare.[^7] J-codes, on the other hand, are permanent HCPCS drug codes recognized across all payers, both government and commercial.[^7]

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This transition signals that Spravato's coding has matured in the system. It's moving from a temporary commercial-only code to a permanent code with broader recognition.

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Reimbursement for Spravato J-code

Here's where things get complicated. Some practices are reporting lower reimbursement with J0013 compared to what they received under S0013. One community member reported a $90 drop per treatment.

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This varies by payer contract. A few things could be happening:

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• Your contracted rate for J0013 may differ from your S0013 rate
• J0013 may not have been automatically added to your fee schedule
• Some payers may be applying different pricing methodologies

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If you're seeing unexpected reimbursement changes, contact your payer rep to confirm what rate is tied to J0013 in your contract.

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Payer-Specific Guidance

Not all payers are handling this the same way. Here's what we've confirmed from official policy documents:

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Highmark (PA, WV, DE, NY)

Highmark's reimbursement policy, effective January 1, 2026, is specific about how professional providers should bill:[^2]

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Professional providers should use G2082 or G2083 for the drug, administration, and required observation. Professional providers should NOT unbundle their services and bill using J0013 or J3490.

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J0013 is only to be used when a specialty pharmacy supplies the drug on a separate claim. If you're a professional provider doing buy-and-bill, continue using the G-codes.

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This is an important distinction. Billing J0013 when you should be using G-codes could result in claim rejections.

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BCBS Florida

BCBS Florida revised their medical coverage guideline on January 1, 2026, adding J0013 and removing S0013.[^3] Their policy documentation reflects the updated coding, and existing prior authorization criteria remain in place.

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Iowa Medicaid

Iowa Medicaid and the managed care organizations now require J0013 for Spravato claims as of January 1, 2026.[^4] There's one exception: for Medicare crossover claims, continue using G2082 or G2083.

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Here's the part that requires action: providers with existing S0013 prior authorizations need to have them modified to J0013.[^4] This isn't automatic. You'll need to contact the MCO to make this change.

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Spravato J-code Prior Authorizations

This is where practices are running into the most trouble. We've been collecting reports from clinicians and from a Patient Access Specialist representing Johnson & Johnson, who has been tracking payer responses across the country.

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Aetna: Generally honoring existing S-code prior authorizations until they expire. When your PA comes up for renewal, reauthorize under J0013.

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BCBS of South Carolina: Requiring ALL prior authorizations to be redone. No advance warning was given. Reauthorizations are proving difficult for some practices.

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If you're working with BCBS SC, here's what J&J recommends:

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• Call to confirm your PAs on file are still valid
• Be prepared to complete the PA over the phone to knock it out in one call
• Make sure they understand these are reauthorizations, not new patients
• Include comprehensive documentation: medication trial history, baseline scales, current outcome scales, and a letter of medical necessity
• Watch out for incorrect denials citing "TRD AND MDSI" criteria. That's not part of their actual policy for TRD patients. If you get this type of denial, highlight the TRD-specific section of their criteria in your appeal.

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BCBS of NJ / Horizon NJ: Both S and J codes are still appearing in benefit verification systems. This suggests their systems may not be fully updated yet.

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General Pattern: Most plans have added J0013 to their prior authorization policies, but their claims processing systems aren't always updated. You cannot assume your existing PAs will process correctly just because the policy has changed.

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What to Do Right Now

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For All Practices:

1. Verify benefits using BOTH codes. During this transition period, check both S0013 and J0013 when verifying patient benefits. This helps you understand where each payer stands.
2. Call payers directly. Don't assume your existing prior authorizations are valid. Call and confirm, especially for patients with upcoming treatments.
3. Contact your payer rep. Ask specifically:
   • Has J0013 been added to my contract?
   • Was it added automatically or do I need to request it?
   • What is my reimbursement rate for J0013?
   • Are my existing S0013 prior authorizations being honored?
4. Confirm your fee schedule. Check that J0013 appears on your fee schedule with the expected reimbursement rate. If it's missing or the rate seems off, escalate to your payer rep.
5. Document everything. Keep records of all payer communications, including who you spoke with, the date, and what they confirmed. You may need this if claims are denied.

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For Buy-and-Bill Practices Specifically

The financial stakes are higher here. If a patient's benefits lapse or a prior authorization isn't valid, you could be out over $1,000 for medication you've already purchased and administered.

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• Confirm PA validity before EVERY medication order. Not just at the start of treatment. During this transition, check before each order.
• Don't rely on benefit verification alone. Benefits can change between verification and treatment day. Verbal confirmation of PA validity adds another layer of protection.
• For reauthorizations: Clearly indicate this is a "reauthorization, not new patient" when submitting. Include comprehensive documentation upfront to reduce back-and-forth.

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Documentation Checklist for Reauthorizations

Based on what's working in the field, here's what to include when submitting reauthorization requests:

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• Medication trial history: List of antidepressants tried and failed, with doses and durations
• Baseline depression scale: The score from your original approval (PHQ-9, MADRS, or whichever scale you used)
• Current outcome scales: Recent scores showing the patient's response to treatment
• Letter of medical necessity: Brief narrative outlining treatment history, current status, and why continued treatment is indicated
• For BCBS plans: Print their criteria and highlight the TRD-specific section. Some reviewers have incorrectly applied combined TRD/MDSI criteria to TRD-only patients.

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What About Medicare?

Medicare continues using G2082 and G2083. The J0013 code is primarily for commercial payers.

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For Medicare crossover claims, continue using the G-codes.[^4]

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TRICARE note: TRICARE only allows buy-and-bill using G2082 and G2083. S0013 and J3490 are not reimbursable for TRICARE patients.

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What We're Still Learning

We're early in this transition, and experiences vary significantly by state and payer. Here are the questions we're still tracking:

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• Contract updates: Are J-codes being automatically added to provider contracts, or do providers need to specifically request this?
• Reimbursement rates: What's actually happening with reimbursement under J0013 vs. S0013? Is it payer-specific or regional?
• PA handling: Which states and plans are requiring full prior authorization redos vs. honoring existing authorizations?

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If you're working through this transition, we'd like to hear what you're seeing. The more data points we collect, the better guidance we can provide to the community.

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TL;DR

The new J0013 code for Spravato replaced S0013 on January 1, 2026.[^1] Payers are handling this inconsistently. Some honor existing prior authorizations; others are requiring them to be redone entirely.

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Your action items:

1. Call your payers to verify PA validity before ordering medication
2. Confirm J0013 is on your fee schedule with the expected rate
3. Document all payer communications
4. For buy-and-bill: verify before every order during this transition
5. Some payers (like Highmark) explicitly state professional providers should NOT use J0013 and should continue using G-codes[^2]
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Medicare billing is unchanged. Continue using G2082 and G2083.

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Stay Updated

Join the Osmind Psychiatry Collective to stay current on what clinicians are learning about the J0013 transition. Share your experiences, ask questions, and help us build better guidance for the community.

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References

[^1]: AAPC Knowledge Center. "CMS Releases 2026 Update to HCPCS Level II." December 2, 2025. https://www.aapc.com/blog/93675-cms-releases-2026-update-to-hcpcs-level-ii/

[^2]: Highmark. "Reimbursement Policy Bulletin RP-083: Spravato® (esketamine)." Effective January 1, 2026. https://providers.highmark.com/claims/reimbursement-resources/reimbursement-policies/rp-083

[^3]: Florida Blue / BCBS Florida. "Medical Coverage Guideline 09-J3000-37: Esketamine (Spravato®) Nasal Spray." Revised January 1, 2026. https://mcgs.bcbsfl.com/MCG?mcgId=09-J3000-37

[^4]: Iowa Health & Human Services. "Claims & Billing - Spravato." January 2026. https://hhs.iowa.gov/medicaid/provider-services/claims-billing

[^5]: CareNet GPO. "CMS 2026 Spravato Codes." December 10, 2025. https://carenetgpo.com/shared-resources/f/cms-2026-spravato-codes

[^6]: Centers for Medicare & Medicaid Services. "Healthcare Common Procedure Coding System (HCPCS)." https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system

[^7]: IPD Analytics. "Medical Drug Coding and Reimbursement 101." https://www.ipdanalytics.com/post/medical-drug-coding-and-reimbursement-101

Last updated: February 2026.

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