Ketamine Out-of-Network Billing Code Guide

min read

August 21, 2023

3 min read

February 18, 2026

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This guide is designed to offer a comprehensive understanding of ketamine billing codes for innovative psychiatry practices who are generating superbills for patient out-of-network reimbursement.

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Disclaimer: The use of ketamine for depression and other mood disorders represents off-label usage. Insurance companies typically do not reimburse for off-label usage; in fact, many payers declare ketamine for mood disorders "experimental" and that they do not reimburse for it. Because many payers consider IV ketamine for mood disorders investigational or non-covered, practices should carefully review their payer agreements if they elect to submit in-network claims for ketamine-related services, including associated E&M services.

This guide shares observations from out-of-network superbill submission. Clinics can generate superbills, give them to their patients, and patients can submit for out-of-network reimbursement.

We cannot guarantee that these suggestions will work for your clinic. Should you have further questions, please consult a healthcare attorney or billing expert.

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We'll cover:

• What is out-of-network superbill submission
• Compliance considerations for out-of-network superbill submission for ketamine services
• The role of billing codes in superbill generation, and the nuances around ketamine
• Types of billing codes relevant to ketamine practices generating superbills
• Billing codes for ketamine infusion, IM injections, KAP, psychotherapy, E&M, and measurement-based care
• Putting it all together: Ketamine superbill generation principles

What is Out-of-Network Superbill Submission?

Out-of-network superbill submission is the process where a patient pays a healthcare provider upfront and then submits a detailed receipt—called a superbill—to their insurance company to request reimbursement.

A superbill is an itemized document created by a licensed healthcare provider that includes all the information an insurance company needs to process a claim.

It typically contains:

• Provider name, credentials, NPI number
• Practice Tax ID (TIN)
• Diagnosis codes (ICD-10)
• Procedure codes (CPT/HCPCS)
• Date(s) of service
• Fee charged
• Place of service

Unlike in-network billing, the provider does not have to be in-network credentialed with an insurance company. The provider does not send the claim directly to insurance. Instead, the patient submits the superbill to their insurance company themselves.

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How Out-of-Network Superbill Submission Works

1. Patient receives care: The patient sees an out-of-network provider and pays at the time of service.
2. Provider issues a superbill: The provider generates a compliant superbill with all required billing codes.
3. Patient submits to insurance: The patient uploads or mails the superbill to their insurance company, often using a standard claim form such as the CMS-1500.
4. Insurance reviews the claim: The insurer determines whether out-of-network benefits apply, the allowed amount, whether the deductible has been met, and the coinsurance rate.
5. Patient receives reimbursement: If approved, the insurance company reimburses the patient directly based on their plan benefits.

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Compliance Considerations for Out-of-Network Superbill Submission for IV Ketamine

When offering IV ketamine therapy for depression or other mental health conditions, many practices operate on a cash-pay basis and provide patients with a superbill upon request. While this model is common, there are important compliance considerations—especially if your practice is in-network with commercial insurers for other services.

Below are key legal and contractual issues providers should understand when using out-of-network superbill submission for ketamine therapy. Consult a healthcare attorney for further guidance and specifics to your practice.

1. Confirm the Service Is Truly Non-Covered

Most commercial insurers consider IV ketamine for depression to be investigational or not medically necessary. However:

• Coverage policies vary by payer and plan.
• Some CPT codes used for infusion (such as 96365) are covered in other clinical contexts.
• A service may be non-covered for a specific diagnosis but not universally excluded.

Key takeaway: Always review your payer agreement's sections on "non-covered services," "billing obligations," and "assignment of benefits."

2. Avoid Misrepresentation of Coverage

When offering out-of-network superbills for ketamine therapy:

Do not tell patients:
• "Insurance will reimburse this."
• "You'll definitely get money back."

Instead, clearly disclose:
• IV ketamine is often considered investigational.
• Reimbursement is not guaranteed.
• The patient is financially responsible for payment regardless of insurance outcome.

Transparent communication reduces fraud risk and protects against payer complaints.

3. Use a Clear Financial Responsibility Policy

Your consent and financial agreement should state:

• IV ketamine is provided on a cash-pay basis.
• The practice does not guarantee insurance reimbursement.
• The patient is responsible for full payment at time of service.
• A superbill can be provided upon request.

This documentation helps demonstrate that you are not attempting to circumvent insurance billing rules.

4. Understand Assignment of Benefits (AOB)

An Assignment of Benefits (AOB) allows an insurer to pay reimbursement directly to the provider instead of the patient.

For most cash-pay ketamine practices:

• An AOB is not necessary if the patient submits the superbill themselves.
• Reimbursement, if any, goes directly to the patient.
• The provider does not interact with the payer.

Using an AOB and attempting to collect directly from the insurer may increase compliance complexity—especially if you are in-network with that payer for other services.

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5. Do Not Selectively Waive Fees

Federal and state fraud laws prohibit improper inducements. Avoid:

• Waiving fees for some patients but not others
• Advertising "we'll help you get reimbursed" in a misleading way
• Structuring payment to influence insurance outcomes

Consistency in pricing and billing policies is critical.

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6. Medicare Considerations

If you participate in Medicare:

• You generally must bill Medicare for covered services.
• You cannot privately contract for covered services unless formally opted out.
• Ketamine for depression is typically non-covered, but you must verify Medicare rules carefully.

Medicare compliance rules are stricter than commercial payer rules.

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Best-Practice Compliance Model for IV Ketamine Superbills

For most in-network psychiatry practices offering IV ketamine:

1. Operate on a transparent cash-pay model.
2. Collect payment at time of service.
3. Provide a properly coded superbill upon request.
4. Allow the patient to submit the claim independently.
5. Avoid submitting claims yourself unless contractually required.

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This approach reduces audit risk, minimizes contractual violations, and maintains compliance with payer agreements.

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What is the Role of Ketamine Billing Codes and Initial Procedures?

CPT codes are integral to healthcare practices. They streamline the billing and claims process, aiding in compliance and potentially facilitating reimbursement. Although insurance typically does not cover specific treatments like ketamine given its off-label usage for mood disorders, the usage of these codes allows the generation of superbills for patients. These documents can subsequently aid patients in seeking potential reimbursement.

What Are CPT Codes, J Codes, HCPCS Codes, Modifiers, and ICD-10 Codes?

Medical billing is its own language. Besides CPT codes, you have J-codes, HCPCS codes, modifiers, ICD-10/DX codes.

This table summarizes the key differences between code types and when to use them:

Code Type	Description	When to Use
CPT codes	Current Procedural Terminology codes are codes that indicate what type of service was performed and via what method.	Used to describe evaluation and management services, such as office visits and consultations.
J codes	J codes are codes used for injectable drugs, usually in an outpatient setting.	Includes the name of the drug, dosage, and method of delivery.
HCPCS codes	Healthcare Common Procedure Coding System codes used to describe medical procedures and services.	Used to describe medical procedures and services not covered by CPT codes, such as durable medical equipment or ambulance services. They get broken down into 3 categories and are not often used by non-facility locations.
Modifiers	Codes used in conjunction with CPT codes to provide additional information about a medical service.	Used to provide additional information about a service, such as that a service was provided by a physician assistant or nurse practitioner rather than the physician.
ICD-10 / DX codes	International Classification of Diseases codes used to describe diagnoses and medical conditions.	Used to describe the diagnoses or medical conditions being treated, such as depression, anxiety disorder, or obsessive-compulsive disorder.

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Playing It Safe with Ketamine Billing Codes for Superbill Submission

To avoid potential issues with insurance companies, it's important to play it safe with billing codes for ketamine practices, even for out-of-network superbills for patients. Only add services that were medically necessary and properly documented. Avoid unbundling or adding ancillary procedure codes unless clearly supported by documentation and CPT guidelines. Adding more procedure codes should only be done with the correct use of modifiers and CPT codes, and the codes listed on the prior authorization should match those listed on the fee schedule. It's also recommended to remove J codes for ketamine from the superbill, as insurance companies generally give very little reimbursement for the drug itself.

Now let's cover the latest ketamine billing codes that every ketamine and interventional psychiatry practice needs to know:

• Ketamine infusion
• IM injections
• KAP (Ketamine-assisted psychotherapy)
• Psychotherapy
• Office visits, Evaluation and Management (E&M)
• Measurement-based care

Ketamine Infusion/IV Billing Codes

Code	Description	Note
96365	Primary code for infusions, up to 1 hour.	This is the code that virtually all IV ketamine providers use for superbill submission and may be the highest yield.
96366	Additional hour of sequential infusion.	Add-on code for 96365 and 96367: Report for additional hour of sequential infusion. Report 96366 with 96365 to identify each subsequent infusion of the same drug.
96367	IV infusion of new drug, up to 1 hour.	IV infusion, for therapy, prophylaxis, or diagnosis; additional sequential infusion of a new drug; up to 1 hour.
96368	Concurrent IV infusion.	IV infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion.
96375	Additional sequential IV push of a new drug.	Add-on code for 96365 and a few others. Report 96375 to identify IV push of new drug after an initial service is administered.
96374	Initial push or infusion less than 16 minutes.	Therapeutic, prophylactic, or diagnostic injection; initial push or infusion less than 16 min.

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Ketamine IM Injection CPT Codes

Code	Description	Note
96372	Therapeutic, prophylactic, or diagnostic injection, SC or IM.	Ketamine IM Injection CPT code.

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Office Visit, Evaluation and Management (E&M), Prolonged Services CPT Codes

There are unfortunately lots of rules around billing using E&M codes. To reduce the probability of rejected claims, please make sure to follow all of them. Here is some guidance from CMS.

E&M Codes Explained: Time, Severity, and Complexity Levels

Evaluation and Management (E&M) codes are CPT codes used to bill for office visits and outpatient medical services. In psychiatry and other outpatient specialties, E&M levels are selected based on either:

• Total time spent on the date of service, or
• Medical Decision-Making (MDM) complexity

Since the 2021 CPT updates, history and physical exam elements no longer determine the level. Coding is driven by time or MDM.

New Patient E&M Codes (99202–99205)

Use for patients not seen by you (or your specialty in your group) within the past 3 years.

Code	MDM Level	Time	Severity
99202	Straightforward	15–29 minutes	Minimal problem
99203	Low Complexity	30–44 minutes	Stable or mild condition
99204	Moderate Complexity	45–59 minutes	Moderate illness, prescription drug management
99205	High Complexity	60–74 minutes	Severe or high-risk condition (e.g., suicidality, psychosis)

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Established Patient E&M Codes (99212–99215)

Use for follow-ups that occur within 3 years of seeing the patient by the same provider or by another provider of the same specialty in the same group practice.

Code	MDM Level	Time	Typical Use
99212	Straightforward	10–19 minutes
99213	Low Complexity	20–29 minutes	Stable follow-up
99214	Moderate Complexity	30–39 minutes	Medication adjustments, worsening symptoms
99215	High Complexity	40–54 minutes	Severe exacerbation, significant safety risk

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When to Use Modifier 25 with an E&M Code

Modifier 25 is used when a provider performs a significant, separately identifiable E&M service on the same day as a procedure.

You may append modifier 25 to the E&M code when:

• The visit includes evaluation and management beyond the usual pre- or post-procedure work.
• The E&M service addresses additional problems or requires meaningful medical decision-making.
• Documentation clearly supports that the E&M service was separate from the procedure.

Common psychiatry and interventional examples:

• A medication management visit on the same day as a TMS treatment session.
• A psychiatric evaluation performed on the same day as a Spravato administration.
• A safety assessment conducted during a procedure visit that goes beyond routine monitoring.

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Do not use modifier 25 when:

• The E&M service is only related to the routine pre-service evaluation of the procedure.
• The documentation does not show distinct work.

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Improper use of modifier 25 is a common audit trigger, so documentation must clearly demonstrate that the E&M service was separate and medically necessary.

Note: Time spent monitoring an infusion cannot be counted toward time-based E&M billing.

Code	Description	Note
99202–99205	New patient E&M	Initial assessment on a visit where no treatment was provided. Include the 25 modifier if billed on same date as infusion.
99212–99215	Established patient E&M	Used if additional services were provided on top of the infusion (e.g. assessing patient). Include the 25 modifier if billed on the same date as infusion.

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Ketamine-Assisted Psychotherapy (KAP) / General Therapy CPT Codes

Non-Evaluation and Management (E&M) Codes

Code	Description
90832	Individual psychotherapy, 30 minutes with the patient and/or family member (time range 16–37 minutes)
90834	Individual psychotherapy, 45 minutes with the patient and/or family member (time range 38–52 minutes)
90837	Individual psychotherapy, 60 minutes with the patient and/or family member (time range 53 minutes or more)
90839	Psychotherapy for crisis, first 60 minutes (time range 30–74 minutes)
90840	Add-on code to 90839 for each additional 30 minutes beyond the first 74 minutes
90853	Group psychotherapy (other than multiple-family group)
90846	Family Psychotherapy (without the patient present)
90847	Family Psychotherapy (with the patient present)
90791	Psychiatric diagnostic evaluations without medical services
90792	Psychiatric diagnostic evaluation with medical services
96127	Used for conducting assessments like BDI, PHQ9 (max of 4 units per quarter). See also: Measurement-based care section.

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E&M Billing Codes

Code	Description
90833	Add-on code for 30-minute psychotherapy session, if coupled with E&M
90836	Add-on code for 45-minute psychotherapy session, if coupled with E&M
90838	Add-on code for 60-minute psychotherapy session, if coupled with E&M

Note: Prolonged codes (G2212, 99417) cannot be used with therapy add-on codes.

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Measurement-Based Care Billing Codes

You can actually use billing codes for your practice of measurement-based care using the Osmind platform! These codes are generally covered by major insurance companies, although payers may specify certain diagnosis codes that should be present or certain questionnaires to use for each code.

96127: Behavioral health assessment — this is the primary code

"Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder scale), with scoring and documentation, per standardized instrument."

Many payers allow up to four units per date of service when separate standardized instruments are administered, but payer policies vary.

Screening may be administered by any staff member, but the assessment must be completed by the provider that's billed under; in this case, a qualified healthcare provider, typically an MD, DO, NP, PA, or PsyD.

A patient self-assessment such as the PHQ-9 qualifies; however, the provider must review, score, and document the results in the medical record.

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Putting It All Together: Ketamine Superbill Generation Principles

1. Conduct your patient visit‍
• Leverage Osmind's purpose-built chart note templates for adequate clinical documentation
• Include relevant diagnosis codes linked to each CPT code
• Make sure there is a time stamp of treatment start/stop
• Dose administered
• Route of administration
• Medical necessity rationale
• Safety monitoring documentation
• Separate documentation of any E&M services

2. Generate superbill‍
• Select appropriate coding reflective of visit
• Allocate cash pay amount across the codes
• Note that E&M codes (99202–99205, 99212–99215) are typically higher value services than infusion code 96365; allocate most of the dollar value to the E&M code

3. Share superbill with patient; patient can submit for potential out-of-network reimbursement through their insurance company

In terms of selecting the final set of codes reflective of your visit, Osmind clinics have had most success simplifying with a short set of codes which typically represent the bulk of possible out-of-network reimbursement for patients.

For example, insurance companies typically reimburse very little (sometimes just a dollar or two) for the ketamine drug itself (identified by the J code J3490). Because reimbursement for ketamine itself (often reported under J3490 or other unclassified drug codes) is typically minimal and may trigger additional processing requirements, some clinics elect not to include the drug code on patient-generated superbills. If you want to include the J code, you MUST provide the 11-digit NDC code, dosage, and unit of measure.

Example: $500 40-Minute Infusion for an Established Patient

Code	Description	Allocation
99214 with 25 modifier	Established patient E&M, moderate complexity	$250
96365	IV infusion, up to 1 hour	$200
96127	Behavioral health assessment	$50

Important: An E&M code should not automatically be billed with every infusion. Modifier 25 may only be used when a significant, separately identifiable evaluation and management service was performed beyond routine pre- and post-infusion care. If you did not conduct separate E&M services outside of the infusion, then only use either the E&M code (no modifier) or the 96365 infusion code, not both.

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Common Issues

Superbills may be rejected for the below common reasons:

• Billing E&M with modifier 25 with every infusion
• Counting infusion monitoring time as E&M time
• Billing psychotherapy during infusion without separate documentation
• Waiving fees selectively
• Using high-level E&M codes without moderate/high MDM

Conclusion

Practices offering ketamine should avoid in-network billing unless explicitly allowed by a payer's medical policy. Practices can generate superbills for patients to submit for reimbursement directly from their insurance company. While the success varies dramatically depending on the payer & specific plan, this is a relatively low-effort way to extend a gesture to the patient while removing the clinic from dealing with the payer directly.

Because of this, it's essential for private mental health practices to be well-versed in the various code sets and know how to use them correctly when providing a superbill for out-of-network ketamine services. This includes being familiar with the different types of codes, when to apply each one, and the correct use of modifiers and ICD-10/DX codes.

Inaccurate or incorrect coding can lead to reduced or nullified out-of-network reimbursement to patients, so it's important to have a thorough understanding of the coding requirements and stay up-to-date with changes in the coding rules and regulations.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.

Healthcare Common Procedure Coding System (HCPCS) is also available in the Osmind platform. It may also be helpful to work with a medical billing specialist or to consult with billing and coding resources and guides to ensure that all coding and billing requirements are met.