Ambulatory BP monitoring
Patients must meet three criteria for Medicare to cover ambulatory BP monitoring.
Medicare pays for codes 93784, 93786, and 93790.
Some private carriers cover more codes.
Medicare covers ambulatory blood pressure monitoring for patients with suspected white-coat hypertension, but document, document, document are the three most important words of advice if you offer this service, says Jean Acevedo, senior consultant at Acevedo Consulting in Delray Beach, FL. Audits are likely.
White-coat hypertension is a condition in which the patient has high blood pressure readings in a medical office but has normal blood pressure at other times. With ABPM, physicians are able to measure and observe fluctuations in the patient's blood pressure readings over a 24-hour-or-longer period using a small blood pressure testing device. They can then use that information to determine if the patient has hypertension or is reacting to the stress of a doctor's office visit.
For Medicare to cover ABPM, the physician must document in the medical record that the patient has had repeated high blood pressure readings in the office and several normal readings outside the office.
"Just having an episode of white-coat hypertension isn't enough," says Diane Maroun, a reimbursement specialist at The Cleveland Clinic Foundation. According to the Medicare Coverage Database guidelines, white-coat hypertension is defined as:
BP reading in the office greater than 140/90 mm Hg on at least three separate visits with two separate measurements made at each visit,
at least two separate, documented BP measurements taken outside the office that are less than 140/90 mm Hg, and
no evidence of end-stage organ damage (such as kidney or heart problems related directly to hypertension).
If the patient doesn't meet these criteria, Medicare won't cover the ABPM, and the monitoring to assess these patients must be done for at least 24 hours for the service to be reimbursable. For example, says Maroun, if the patient removed the monitor before 24 hours had elapsed, the charge couldn't be submitted.
Before subsequent testing, the qualifying criteria must be met. According to the guidelines, "those patients that undergo ambulatory BP monitoring and have an ambulatory BP < 135/85 mm Hg with no evidence of end-organ damage, it is likely that their cardiovascular risk is similar to that of normotensives. They should be followed over time. Patients for whom ABPM demonstrates a BP > 135/85 mm Hg may be at increased cardiovascular risk, and a physician may wish to consider antihypertensive therapy."
Maroun recommends that if you're concerned that the patient may not meet the criteria, have him sign an Advance Beneficiary Notice before the service is performed. This notice informs the patient that Medicare may not pay for the service because of the guidelines indicated above. It explains why the service may not be covered and allows the patient to choose whether to proceed with the service or not.
The ABN must be signed before the service is performed and cannot be given as a "routine blanket" notice. There should be some kind of explanation as to why the physician feels the service may not be covered. Attach the appropriate GA, GY, or GZ modifier when using ABNs.
For patients who meet the criteria for white-coat hypertension, Medicare pays for the following codes:
93784ABPM utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report
93786. . . recording only
93790. . . physician review with interpretation and report.
Note: Medicare won't pay for another code in that series, 93788 (. . . scanning analysis with report). Use 796.2 (elevated BP reading without diagnosis of hypertension) because there's no specific diagnosis code for white-coat hypertension.
The pool of patients likely to be affected by Medicare's coverage of ABPM may not be as large as many expect, notes Donald G. Vidt, director of the Ambulatory Blood Pressure Monitoring Laboratory and a consultant in the department of hypertension and nephrology at The Cleveland Clinic Foundation.
"There's a very narrow window of coverage," Vidt says.
About a quarter of patients with elevated BP readings in a medical office have some degree of white-coat hypertension, but most of them are not Medicare patients. About 95 percent of hypertension is the essential type, and most cases are diagnosed in patients between the ages of 30 and 50. Those diagnosed at a later age usually have secondary hypertension as a result of another disease state, such as a renal or thyroid disorder.
Ambulatory BP monitoring can be useful in evaluating a broader range of patients, including those whose medications appear not to be working well in lowering BP, but Medicare will not pay for it in those situations, Vidt says.
Although commercial insurers have only recently begun paying for ABPM, some will pay for a wider variety of reasons than Medicare does. Those include hypertension that's resistant to medication and intermittent episodes of lightheadedness or other problems that the physician suspects may be related to hypertension.
Ask your local payers for more information on their coverage. You can get more details on Medicare coverage of ABPM online. See Transmittal AB-01-188 at cms.hhs.gov/manuals/pm_trans/AB01188.pdf, and Section 50-42 of the Medicare Coverage Issues Manual at cms.hhs.gov/manuals/06_cim/ci50.asp#_ 50_42.
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Coding Consult: Ambulatory BP monitoring. Medical Economics 2003;7:20.