Patient Nervous About Doctors? Update Medicare Coverage Rules for ABPM

Medicare coverage of blood pressure monitoring

A recent update brought Medicare coverage changes for both suspected white coat hypertension and suspected masked hypertension. Here’s your chance to get a handle on the new rules, including a change to the threshold for hypertension.

Keep Patients Calm With New ABPM Coverage

Medicare coverage of ambulatory blood pressure monitoring (ABPM) for patients with suspected white coat hypertension is not new, but the recently released Decision Memo for Ambulatory Blood Pressure Monitoring (ABPM) makes changes to the numbers involved. Let’s take a closer look.

New: The decision memo states that Medicare covers ABPM for beneficiaries with suspected white coat hypertension, which is basically when a patient’s blood pressure measures high because of the stress of being at the doctor’s office. The new decision memo changes the official Medicare definition to “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.”

Old: The previous definition was office blood pressure greater than 140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit, at least two documented blood pressure measurements taken outside the office which are less than 140/90 mm Hg, and no evidence of end-organ damage.

Help Hypertension Hiders With Added Coverage

Patients whose blood pressure goes up at the doctor’s office aren’t the only ones to benefit from this coverage decision. The update adds coverage for beneficiaries with suspected masked hypertension, which may affect 28 percent of people older than 65, according to the decision memo.

Here’s the definition you need to know for this condition which leads to a lower blood pressure reading at the doctor’s office: “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.”

Work Through This ABPM Coverage List

The suspected diagnosis isn’t the only item required to meet coverage requirements. Check off these points from the decision memo, too:

  • The device must be able to produce standardized plots of blood pressure measurements for 24 hours and be able to mark normal blood pressure bands. This should include daytime and nighttime windows.
  • Your office should provide the device to the patient with both oral and written instructions. You should run a test in the physician’s office, too.
  • The treating physician or treating non-physician practitioner should interpret the data.
  • Medicare covers ABPM once per year for eligible beneficiaries.

Tip: The ABPM decision memo states that MACs may opt to cover other indications for ABPM.

Match Your ABPM Coding to the Medical Record

The decision memo does not specify the codes involved, but here are some hints.

As we recently covered, you’re likely to see some changes to ABPM codes 93784-93790 in CPT® 2020, so watch for those. Currently, you choose your code based on the components you’re reporting, such as review with interpretation and report.

Your ICD-10-CM coding will depend on the provider’s documentation of the results, but if hypertension is not the final diagnosis, then you may find the most appropriate code is R03.0 (Elevated blood-pressure reading, without diagnosis of hypertension) for white coat hypertension. For hypertension, look at codes such as I10 (Essential (primary) hypertension) and I11.- (Hypertensive heart disease).

There are other possibilities, so know your payer’s specific policy, always code based on the medical record, and follow coding rules using the ICD-10-CM Index, Tabular List, and official guidelines.

What About You?

Are you surprised to see ABPM coverage expand? How do you keep track of coverage rules like blood pressure number requirements?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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