Spravato billing combines medication dispensing, supervised administration, mandatory observation time, and REMS compliance into a single claim. This creates more opportunities for errors than nearly any other behavioral health service.
In 2026, the landscape has shifted: new J-codes have emerged, old prolonged service codes are dead, and payer rules for “split-billing” have tightened. This guide focuses on how Spravato is billed and coded in real clinical workflows today.
1. Core Spravato Billing Models You Need To Understand
Two primary procurement models exist for Spravato. Understanding which applies determines your entire coding approach.
Model A: Medicare & “Bundled” Payers (Buy & Bill)
In this model, your clinic purchases Spravato and bills a single code that covers both the drug and the 2-hour observation time.
The Advantage: Simple billing; no need to count minutes for observation.
The Restriction: You cannot bill separate evaluation (E/M) or prolonged service codes with these.
| HCPCS Code | Description | 2026 Status |
|---|---|---|
| G2082 | Visit + Drug (56 mg) + Observation | Active (Medicare Standard) |
| G2083 | Visit + Drug (84 mg) + Observation | Active (Medicare Standard) |
Model B: Commercial & “Split-Bill” Payers
Most commercial payers (e.g., BCBS, UHC, Aetna) do not accept the bundled G-codes. Instead, you must “unbundle” the service into two parts:
The Drug: Billed by you (if Buy & Bill) or the Specialty Pharmacy.
The Procedure: Billed by you as an Office Visit (99215) + Prolonged Services.
2. The 2026 Drug Codes: J0013, S0013, and J3490
Critical Update: As of January 1, 2026, several major payers have begun adopting J0013, moving away from the “S” codes. You must verify which of these three your payer requires.
| Code | Description | Usage Notes |
|---|---|---|
| J0013 | Esketamine, nasal spray, 1 mg | NEW for 2026. Adopted by Blue Shield CA and others replacing S0013. |
| S0013 | Esketamine, nasal spray, 1 mg | Still the standard for many commercial plans (Aetna, Cigna). |
| J3490 | Unclassified Drug | The “Catch-All.” Use if payer rejects J/S codes. Must include NDC and dosage in claim notes. |
Unit Calculation
56 mg dose = 56 Units
84 mg dose = 84 Units
3. Administration and Observation: The New Rules
STOP: Do not use 99354 or 99355. These codes were deleted and will cause immediate denial.
For commercial “split-billing,” you bill an E/M code (usually 99215) for the visit. However, 99215 only covers 40–54 minutes. Since Spravato requires 2 hours (120 mins) of observation, you must add Prolonged Service codes.
Commercial Payers (Non-Medicare)
Code: 99417
Description: Prolonged outpatient service, each 15 minutes beyond the total time of the primary service (99215).
Logic: If your total time is 120 minutes:
First 55 mins = 99215
Remaining 65 mins = 99417 × 4 units (approx.)
Medicare (If not using G2082/3)
Code: G2212
Description: Prolonged office service, each 15 minutes.
Note: Medicare rarely uses this for Spravato since they prefer G2082/G2083, but if you are billing an E/M visit separately, G2212 is the required add-on, not 99417.
4. Documentation Requirements That Support Clean Claims
Payers audit Spravato claims frequently due to the high cost. Your notes must validate the codes billed.
Time Logs (Critical): You must document the exact start and end times of observation (e.g., “10:00 AM – 12:05 PM”). “Total time: 2 hours” is often insufficient for 99417 billing.
REMS Compliance: Proof that patient monitoring forms were completed and submitted.
Vitals: BP checks recorded at: Pre-dose, 40 mins post-dose, and 120 mins post-dose.
Medical Necessity: Documenting “Treatment Resistant Depression” (failed 2+ prior antidepressants).
5. Common Spravato Billing Mistakes to Avoid
The “Double Dip” Denial
Mistake: Billing G2083 (Bundled) AND 99215 (Office Visit) on the same day.
Reality: G2083 includes the office visit. You cannot bill both. Choose the model that matches your payer’s contract.
Using the Wrong J-Code
Mistake: Continuing to bill S0013 for a payer that switched to J0013 in 2026.
Fix: Check your payer fee schedules for Jan 1, 2026 updates.
Missing NDCs on J3490
Mistake: Billing J3490 without the NDC number in Box 24 or the electronic loop.
Result: Automatic rejection for “Incomplete Description.”
Billing Prolonged Codes with G-Codes
Mistake: Billing G2083 + 99417.
Reality: G2083 already includes 2 hours of observation. You cannot add prolonged services unless the visit goes significantly beyond the standard 2 hours (rare and hard to justify).
