Physicians are better equipped to correctly diagnose Medicare patients with hypertension thanks to a new national coverage policy. The Centers for Medicare & Medicaid Services (CMS) issued, July 2, a final decision memo regarding its national coverage policy for ambulatory blood pressure monitoring (ABPM).

For nearly two decades, Medicare coverage for ABPM has been limited to patients with suspected “white coat hypertension” who are not being treated for high blood pressure. The final decision expands coverage of ABPM in cases of suspected “masked hypertension.”

Proper claims reimbursement of ABPM services relies on accurate diagnosis coding.

The Benefits of ABPM

ABPM is a non-invasive diagnostic test that uses a device to track blood pressure over 24-hour cycles. This allows a doctor to assess a patient’s blood pressure throughout the day, wherever the patient may be, and create an average blood pressure from the aggregate of readings.

Recognize the Types of Hypertension

When coding these claims, make sure the code for ABPM, such as CPT 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 is supported with an allowed diagnosis code; and that the diagnosis is in line with the new blood pressure threshold.

“White coat hypertension” is a condition in which a patient’s blood pressure uncharacteristically rises in a clinical setting.

Per the decision memo, suspected white coat hypertension 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 great 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

“Masked hypertension” is when a patient’s blood pressure is normal in a clinical setting but uncharacteristically rises at other times during the day.

Per the decision memo, suspected masked hypertension 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 ≥ [less than or equal to] 130/80 mm Hg.

Both conditions are reported with ICD-10-CM code R03.0 Elevated blood pressure reading, without diagnosis of hypertension.

For eligible patients, ABPM is covered once per year.

See the decision memo for ABPM for complete details. See also the national coverage determination for ABPM (NCD 20.19).

Related article: CMS Reconsiders “White Coat Hypertension” Limitation