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Internal Medicine Coding Alert

Careful Recordkeeping Is Key to ABPM Reimbursement

Published on Fri Nov 01, 2002

Medicare now covers ambulatory blood pressure monitoring (ABPM) for patients with suspected white-coat hypertension, but coding experts have three important words of advice if you plan to begin offering this to patients: document, document, document.

For Medicare to cover ABPM, the physician must document 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 doesn't get you in the door," says Diane Maroun, CPC, a reimbursement specialist at the Cleveland Clinic Foundation in Cleveland.

Medicare requires that the physician document that the patient had:

  • office blood pressure greater than 140/90 on at least three separate office visits with two separate measurements made at each visit

  • at least two documented separate blood pressure measurements taken outside the office that are less than 140/90

  • no evidence of end-organ damage (such as kidney or heart problems related directly to hypertension).

    If the patient does not meet these criteria, Medicarewill not cover the ABPM. If you have concerns that the patient does not meet the covered criteria, be sure to have him or her sign an advance beneficiary notice (ABN), Maroun recommends.

    Audits are likely as Medicare begins to pay for ABPM, and physicians should be sure to keep the required documentation in the patient's medical record to show medical necessity for the service, says Jean Acevedo, CPC, LHRM, senior consultant at Acevedo Consulting Inc., a national coding and compliance consulting firm in Delray Beach, Fla. You should also include a copy of the test results with the physician's signature in the chart, she says.

    Three Codes Reimbursed for ABPM

    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 patients who meet the criteria above for whitecoat hypertension, Medicare began paying for the following codes effective April 1:

  • 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 recording only

  • 93790 physician review with interpretation and report.

    Note: Medicare will not pay for another code in that series, 93788 ( scanning analysis with report).

    You should use 796.2 (Elevated blood pressure reading without diagnosis of hypertension) as the diagnosis code because there is no specific diagnosis code for white-coat hypertension.

    Although fees will vary slightly by location, the St. Louis-area Medicare carrier pays participating providers $40.68 for 93784, $31.88 for 93786, and $8.80 for 93790.

    Medicare Won't Cover ABPM for Other Reasons

    The Ambulatory Blood Pressure Monitoring Laboratory at the Cleveland Clinic has provided ABPM to patients of affiliated physicians for some time but has not yet begun billing Medicare because of the extensive documentation required, Maroun says.

    Donald G. Vidt, MD, director of the ABPM Laboratory and a consultant in the department of hypertension and nephrology at the Cleveland Clinic, notes that the pool of patients likely to be affected by Medicare's coverage of ABPM may not be as large as many expect.

    About 20-25 percent of the patients with elevated blood pressure readings in an internist's office have some degree of white-coat hypertension, but most of these patients are not Medicare patients, Vidt says. About 95 percent of hypertension is the essential type, and physicians diagnose most cases in patients between 30 and 50 years of age, well before most people begin Medicare coverage, he says. Those diagnosed at a later age usually have secondary hypertension as a result of another disease state, such as a renal or thyroid disorder, he says.

    "That limits the number of patients (covered by Medicare for ABPM)," Vidt says. "It's a very narrow window of coverage."

    ABPM can be very useful in evaluating a broader range of patients, including those whose medications appear not to be working well in lowering blood pressure, but Medicare will not pay for ABPM in that situation, Vidt says.

    Other payers are taking the lead from Medicare, however, and are beginning to pay for ABPM. And some will pay for a wider variety of reasons, such as patients whose hypertension is resistant to medication and those who have intermittent episodes of lightheadedness or other problems that the physician suspects may be related to hypertension, Vidt says. You should ask your local payers for more information on coverage.

    For more information on Medicare coverage of ABPM, see Transmittal AB-01-188 on the Web at http://www.cms.gov/manuals/pm_trans/AB01188.pdf, and Section 50-42 of the Medicare Coverage Issues Manual at http://www.cms.gov/manuals/06_cim/ci50.asp#_50_42.

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