CMS released an NCD for ABPM on July 2, 2019. CMS has expanded the coverage for ABPM by allowing it for a greater range of BP measurements. Of course, there are limits or there wouldn’t be an updated coverage determination.
Neither the CPT® nor the ICD-10 coding has changed, only the eligibility, expanding the covered indications. These are copied from the CMS document into the post, below.
This test measures blood pressure at regular intervals over a 24 hour period, and is covered to evaluate white coat hypertension, possible drug resistant hypertension, and other hypertensive conditions. CMS has changed the range of blood pressures that are covered. More patients may be eligible for the test now that CMS has expanded the range of BP readings.
Some patients get nervous when they go to the doctor’s office, and their nervousness can cause their blood pressure to measure higher in the office than typical for the patients in other situations. The name “white coat syndrome” was coined to describe this phenomenon of a patient’s blood pressure being measured higher in the doctor’s office than their typical blood pressure. We have an ICD-10 code to use for that, R03.0, elevated blood-pressure reading, without diagnosis of hypertension.
Medicare’s prior coverage for ABPM
- Clinic blood pressure >140/90 mm Hg at 3 separate clinic visits with 2 measurements made at each visit
- At least 2 documented BP measurements taken outside the clinic <140/90 mm Hg
- No evidence of end-organ damage
Medicare’s new coverage for ABPM
- The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to cover ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension in Medicare beneficiaries under the following circumstances:
- For beneficiaries with suspected white coat hypertension, which is defined as an average office blood pressure of systolic blood pressure greater than 130 mm Hg but less than 160 mm Hg or diastolic blood pressure greater than 80 mm Hg but less than 100 mm Hg on two separate clinic/office visits with at least two separate measurements made at each visit and with at least two blood pressure measurements taken outside the office which are <130/80 mm Hg.
- For beneficiaries with suspected masked hypertension, which is defined as average office blood pressure between 120 mm Hg and 129 mm Hg for systolic blood pressure or between 75 mm Hg and 79 mm Hg for diastolic blood pressure on two separate clinic/office visits with at least two separate measurements made at each visit and with at least two blood pressure measurements taken outside the office which are ≥130/80 mm Hg.
ABPM devices must be:
- capable of producing standardized plots of blood pressure measurements for 24 hours with daytime and night-time windows and normal blood pressure bands demarcated;
- provided to patients with oral and written instructions and a test run in the physician’s office must be performed; and
- interpreted by the treating physician or treating non-physician practitioner. For eligible patients, ABPM is covered once per year.
- 93784: Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report
- 93786: Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only
- 93788: Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report
- 93790: Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; review with interpretation and report
You can see that 93784 is the global service, and the next three codes break up the components of the service.
|Code||wRVU||Total facility RVU||Total non facility RVU|
And, as mentioned, the diagnosis code is R03.0. Of course, there are other indications for this test, this article discusses only the change in range for white coat syndrome. The test is still covered for hypertensive related disorders.
Citations: The coverage manual will be updated to reflect this. The NCD is 64 pages long, and is filled with clinical information. The coverage information is summarized in Appendix B and C. You can download the entire document here.
The NCD’s identifying number is: (CAG-00067R2)