Who Delivers TMS? The Psychiatrist, the Technician and Why Oversight Matters
TMS is a prescription medical treatment. A physician, ideally a psychiatrist trained in TMS, evaluates the patient, writes the treatment plan, sets the initial dose by finding the motor threshold and coil position, and stays responsible for the course. A trained TMS operator, often called a technician, usually delivers the daily sessions. Physician oversight matters because the important decisions in TMS are clinical ones: whether the diagnosis is right, whether it is safe to stimulate, how to adjust when medications or sleep change, and when to stop.
The APA's 2024 position statement puts it plainly: TMS is "a safe and effective evidence-based medical treatment when administered by TMS-trained psychiatrists for appropriately selected patients." This guide explains who does what, what Medicare and New York payers require, and the questions that reveal how a TMS program is actually supervised.
The roles on a TMS team
The Clinical TMS Society's consensus review describes a team in which the attending physician who prescribes the course is "ultimately responsible for the overall daily management of the TMS treatment team." Most programs look like this:
| Role | Typical responsibilities | What to look for |
|---|---|---|
| Prescribing (attending) physician | Confirms the diagnosis, screens for contraindications and risk factors, sets the treatment plan, performs the first motor threshold and coil placement, reviews progress, manages adverse events, decides on extension, taper or stopping | A psychiatrist with TMS training who sees you before, during and at the end of the course |
| TMS operator (technician) | Positions the coil each day, runs the session at the prescribed settings, monitors comfort and hearing protection, records symptoms and side effects, reports changes | Manufacturer training on the specific device, CPR or basic life support, seizure first-response training |
| Supervising physician on site or nearby | Available during treatment, responds to seizures, fainting or other events | A named physician you can reach, with a clear plan for emergencies |
| Your other clinicians | Therapist, prescribing psychiatrist or primary care physician who continue care alongside TMS | A team that shares updates rather than working in parallel |
The same consensus recommends that the physician, or another physician in the practice, "perform the initial motor threshold determination and identify the appropriate coil location," that later threshold checks may be delegated to qualified staff, and that non-physician operators complete manufacturer training before treating independently. It also recommends that operators hold CPR or basic life support training and that "all clinical personnel involved in the delivery of TMS must be trained as first responders" for a seizure.
Supervision rules from Medicare, Medicaid and commercial payers
Insurers turn these expectations into conditions of payment, and they do not all say the same thing. For a patient in Brooklyn, the main rules are:
| Payer or policy | Who may order | Supervision during sessions |
|---|---|---|
| Medicare, New York (LCD L33398, revised Aug 2026) | A physician (MD or DO) who has examined the patient and has TMS experience; a nurse practitioner or other non-physician practitioner may order within state scope of practice | Direct supervision by a physician, who is present in the area but need not deliver the treatment personally |
| New York State Medicaid | A qualified psychiatrist or independently practicing psychiatric nurse practitioner with specialized training and certification | Administered under that clinician's direct supervision |
| Aetna (CPB 0469) | A psychiatrist (MD or DO) or psychiatric-mental health nurse practitioner | Direct supervision by the ordering clinician; the operator must be in the room at all times |
| Optum / UnitedHealthcare behavioral policy | A qualified psychiatrist, or a psychiatric nurse practitioner in a full-practice-authority state, which includes New York | Ordered, supervised and administered by that clinician |
The Medicare change is recent. The August 2026 revision deleted a sentence that had allowed treatment "under direct supervision of this NPP," to make clear that the person supervising sessions must be a physician. Billing rules also assume physician involvement: the initial treatment code, CPT 90867, covers "cortical mapping, motor threshold determination, delivery and management," and a separate code, 90869, covers re-determining the motor threshold during a course.
Payer policies change, and plan-level details are covered in the coverage guides for Medicare in New York and Aetna, among others.
What a psychiatrist adds before the first session
Most of the value of physician oversight is front-loaded. A careful evaluation answers questions that a device cannot.
Is this really unipolar major depression?
FDA's special-controls guidance lists bipolar disorder and psychotic disorders among populations where efficacy and safety have not been established. Treatment-emergent mania with TMS is uncommon, and pooled sham-controlled data show rates similar to sham, but most published cases occurred in people with bipolar disorder. Missing a bipolar history or a mixed state changes the plan. New York Medicaid also requires providers to "rule out other etiologies of depressive symptoms" before TMS, which is a physician's task. The workup itself is the subject of ruling out medical causes before TMS.
Is it safe to stimulate?
FDA guidance contraindicates rTMS for people with conductive, ferromagnetic or other magnetic-sensitive metal implanted in the head or within 30 cm of the coil, and for implants such as deep brain stimulators, cochlear implants and vagus nerve stimulators. Pacemakers and implantable defibrillators carry a labeled warning rather than a listed contraindication. Sorting a dental filling from an aneurysm clip, or a shunt valve from a stimulator lead, takes records and judgment.
Seizure risk depends on the person. FDA guidance asks for close monitoring of patients with a history of seizure, stroke, head injury or other neurologic disease, and of those taking drugs known to lower the seizure threshold. The 2021 IFCN guideline adds factors a technician may not hear about, such as alcohol withdrawal, stimulant use, low sodium or blood sugar, infection, fever and sleep deprivation.
Is TMS the right next step?
For psychotic depression or acute suicidal ideation, consensus guidance points toward treatments with established efficacy such as ECT. A psychiatrist who knows the alternatives, including medication changes, esketamine and ECT, can say when TMS should wait.
If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
What oversight adds during the course
Dosing in TMS is individual. Intensity is set as a percentage of each patient's motor threshold, determined by visible finger movement, with or without EMG. That threshold can shift. The Clinical TMS Society advises that medication changes "should prompt consideration for reassessment of the patient's motor threshold," and Aetna treats more than one re-mapping per course as medically necessary when a patient is not responding or the threshold may have changed. Deciding when to re-map is a clinical call. The mechanics are explained in motor threshold and TMS dosing and finding the target.
Progress needs to be measured, not guessed. Medicare's billing article requires the attending physician to "monitor and document the patient's clinical progress" and to use validated scales such as the PHQ-9, HAM-D or MADRS. The consensus review recommends repeated mood ratings and daily progress notes from the operator. Regular review lets a physician notice early worsening, new side effects, rising anxiety or the first signs of hypomania, and act on them.
End-of-course decisions also need a physician: whether to taper, whether a non-responder should stop, and how to plan for relapse. When relapse follows a good response, the Clinical TMS Society recommends that TMS "should be reintroduced until remission is re-achieved."
When something goes wrong
Serious adverse events are rare, which is why preparation matters more than frequency. In a survey of clinics covering 2012 to 2016, there were fewer than 0.02 seizures per 1,000 sessions when TMS was given within guidelines to people without risk factors. Seizures were "most likely to occur within the first few exposures to TMS" and more common when guidelines were exceeded. Fainting can look like a seizure, and IFCN 2021 describes how to tell convulsive syncope from a true seizure and how to manage it. A team led by a physician should have a written plan for both, and the operator should know it. The numbers are discussed in detail in TMS safety and seizure risk.
What the evidence does and does not say
The case for physician oversight rests on the safety logic above, on professional consensus and on payer rules that make physician supervision a condition of coverage, rather than on trials comparing one supervision model with another. That is a reasonable basis, but it is worth being clear about which parts are evidence and which are consensus.
It is also true that physician oversight is not the same as the physician pressing the button. Under the Medicare rule, the supervising physician must be present in the area but does not necessarily deliver each session. A trained technician delivering sessions is normal and appropriate. What matters is that a physician owns the diagnosis, the dose and the decisions.
Questions to ask any TMS program
- Who will evaluate me before treatment, and is that person a psychiatrist with TMS training?
- Who determines my motor threshold and coil position at the first session?
- Is a physician on site or nearby during my sessions, and who responds if I faint or have a seizure?
- Which rating scale will track my progress, how often, and who reviews it?
- How will the team handle a medication change, a bad night of sleep or an illness during my course?
- When will I see the physician again, and what happens if I am not improving by the midpoint?
- How will you communicate with my therapist and current prescriber?
A broader checklist for choosing a program is in how to choose a TMS provider in Brooklyn and NYC. Clinicians referring a patient may find the TMS referral guide for therapists and physicians useful. Dr. Lewis's background and training are on the about page, the full set of articles is in the TMS guide, and practical information is on the TMS therapy page.
Frequently asked questions
Does a psychiatrist have to give each TMS session?
No. Trained TMS operators usually deliver the daily sessions. Medicare in New York requires direct physician supervision, meaning a physician is present in the area, but not necessarily in the room for every session.
Can a nurse practitioner order TMS in New York?
Under several policies, yes. New York Medicaid and Optum allow a psychiatric nurse practitioner who can practice independently to order TMS, Aetna allows a psychiatric-mental health nurse practitioner to do so, and Medicare allows non-physician practitioners to order within state scope of practice. Medicare now requires that sessions be supervised by a physician.
Why does the motor threshold need a physician?
The motor threshold sets the dose for every session. Consensus guidance asks the physician to perform the first determination and coil placement because errors carry into the whole course, and because changes in medications or health can shift the threshold later.
Is psychiatrist-led TMS more effective?
Physician oversight is recommended for safety, correct patient selection and timely adjustment, and most payers require it. It has not been shown to raise response rates on its own, and patients should be wary of any program that promises it does.
What training should a TMS technician have?
At a minimum, manufacturer training on the specific device, CPR or basic life support, and training as a first responder to a seizure, according to the Clinical TMS Society consensus.
Sources
- Position Statement on Transcranial Magnetic Stimulation (TMS). American Psychiatric Association, 2024. psychiatry.org
- The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder. Brain Stimulation, 2016. pmc.ncbi.nlm.nih.gov
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
- Billing and Coding: Transcranial Magnetic Stimulation (A57528). Wellpoint Federal via CMS Medicare Coverage Database, 2026. cms.gov
- New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (Medicaid Update, July 2025). NYS Department of Health, 2025. healthweb-back.health.ny.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation. Optum Behavioral Health Solutions, 2026. providerexpress.com
- Transcranial Magnetic Stimulation: Full Practice Authority Nurse Practitioner States. Optum Behavioral Health Solutions, 2026. providerexpress.com
- Class II Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. U.S. FDA, 2011. fda.gov
- Treatment-emergent mania in unipolar and bipolar depression: focus on repetitive transcranial magnetic stimulation. International Journal of Neuropsychopharmacology, 2008. europepmc.org
- Hypomanic/manic switch after transcranial magnetic stimulation in mood disorders: A systematic review and meta-analysis. World Journal of Psychiatry, 2021. europepmc.org
- Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: Expert Guidelines. Clinical Neurophysiology, 2021. europepmc.org
- Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Journal of Clinical Psychiatry, 2018. pmc.ncbi.nlm.nih.gov
- K220177 510(k) Summary: Magnus Neuromodulation System with SAINT Technology. U.S. FDA, 2022. accessdata.fda.gov
- Seizures from transcranial magnetic stimulation 2012-2016: Results of a survey of active laboratories and clinics. Clinical Neurophysiology, 2019. europepmc.org
Educational information, not medical advice. Whether TMS or any treatment fits you is a decision to make with a psychiatrist who knows your history.
The information provided on this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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