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Primary Care Coding Alert

New CMS Coverage:

Cash In on ABPM

Published on Thu Aug 01, 2002

Family physicians who provide ambulatory blood pressure monitoring (ABPM) can now receive Medicare reimbursement for it.

Beginning April 1, 2002, Medicare covers ABPM services performed for patients with suspected white-coat hypertension, according to Medicare transmittal 149. To meet the Medicare coverage criteria, the FP must perform ABPM only for patients with suspected white-coat hypertension. And the ABPM must occur for at least 24 hours. (See related story in article two.)

"Although CPT codes exist for ABPM, CMS did not previously pay for them," says Michael Ernst, PharmD, BCPS, co-director of the ABPM referral service in the Family Care Center of the University of Iowa Hospitals in Iowa City.

FP coders billing for ABPM can choose from three different codes:

  • 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. Use this code when the FP provides both the technical and professional components. It represents the global service. The Medicare-allowed amount for 93784 is $43.08.
  • 93786 ... recording only. Use this code when the FP provides the technical component only. "The FP will place the device and then send it to a cardiologist or nephrologist for interpretation," Ernst says. The technical component involves programming and fitting the monitor, as well as patient education. The Medicare-allowed amount for 93786 is $34.03.
  • 93790 ... physician review with interpretation and report. FPs providing only the professional component should use this code. The Medicare-allowed amount is $9.05.

    Watch Out for 93788

    While Medicare will reimburse the above three codes under the new policy, it still does not cover the other ABPM code, 93788 (... scanning analysis with report).

    And, "because commercial carriers often follow Medicare's lead, many will deny this code as well," Ernst says. Family practices should check with their individual carriers to see if they cover 93788.

    Get Paid for Each Additional Test

    In the rare circumstance that the FP performs more than one ABPM on a patient, the practice must meet the same Medicare criteria for each subsequent test.

    Ernst offers the example of a patient with an existing hypertension diagnosis who is also determined to have white-coat hypertension after an ABPM test. Though the patient is medicated, his blood pressure remains elevated on follow-up visits. The physician may conduct another ABPM test to determine if the high blood pressure is a result of the white-coat hypertension or if the medication is not controlling the actual hypertension.

    The FP can bill the appropriate ABPM code for the second test if he or she followed the Medicare requirements. "The Medicare memorandum does not say that the patient can't be on medication for an ABPM," Ernst says. "This means doctors can perform the test more than once, if necessary."

    Bill Office Visit When Appropriate

    Usually, Ernst says, the FP schedules a separate visit to place the monitor after the initial office visit. Code this separate visit with the appropriate ABPM code. If the physician attaches the ABPM monitor to the patient during a regular office visit, you can code separately for the encounter with the appropriate-level E/M code (99201-99215).

    It's not necessary to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Practice in Leawood, Kan. The ABPM is a diagnostic test, not a procedural service, and CPT doesn't include such tests in the E/M service, Moore says

    You cannot code the return visit along with the E/M because it is set up solely to detach the ABPM.

    Note: To view the CMS ABPM rules, go to www.hcfa.gov/pubforms/06_cim/ci50.htm#_50_42.

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