Primary Care Coding Alert

NCD updates criteria, thresholds for hypertensive beneficiaries.

On July 2, the Centers for Medicare and Medicaid Services (CMS) announced changes in its national coverage determination (NCD) for ambulatory blood pressure monitoring (ABPM).

The decision “reflects CMS’ commitment to continually updating our policies to ensure that more Medicare beneficiaries have access to the latest technology and appropriate evidence-based health care” and “to improving cardiovascular health in the Medicare population,” said CMS Administrator Seema Verma in the press release that accompanied the NCD (Source:  www.cms.gov/newsroom/press-releases/cms-expands-coverage-ambulatory-blood-pressure-monitoring-abpm).

The change probably won’t affect your coding significantly according to our experts. Even so, it’s worth understanding the determination’s key provisions, if for no other reason than it’s always good to brush up on your ABPM coding knowledge.

What the Determination Does

Essentially, the NCD outlines three areas of coverage expansion.

Masked hypertension now covered. Previously, CMS only covered ABPM for patients with suspected white coat hypertension, a phenomenon that happens when a patient’s blood pressure is higher in the clinical environment than it is outside it. With this NCD, CMS expands ABPM to masked hypertension, a condition where the patient’s blood pressure is the opposite — higher outside of the clinical environment than in it.

Hypertension threshold lowered. CMS has also followed the recommendations of professional societies such as the American College of Cardiology and the American Heart Association in the NCD and adopted a threshold of 130/80 for ABPM, down from the previous policy threshold of 140/90.

Device criteria outlined. The NCD also outlines guidelines for the monitor itself and the way your practitioner must administer it to a patient. ABPM devices must be:

• able to produce standardized plots of blood pressure measurements for 24 hours with daytime and nighttime windows separated from normal blood pressure bands.
• given to the patient with oral and written instructions and a test run in the physician’s office.
• interpreted by the treating physician or treating nonphysician practitioner.

These coverage changes have been welcomed by coding experts. “This is a positive change in CMS guidelines that will allow the providers to get a more accurate picture of a patient’s blood pressure,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

What the Determination Means

For the most part, your coding of the service won’t change, as both ICD-10 and CPT^® coding will essentially stay the same.

Dx won’t change: Even though CMS has widened the coverage conditions to include masked hypertension, you’ll still report the same ICD-10 code to justify the service. That’s because “a patient with  an episode of elevated blood pressure in whom no formal diagnosis of hypertension has been made, or who has an isolated incidental finding, will still be coded as R03.0 [Elevated blood-pressure reading, without diagnosis of hypertension],” according to Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. In other words, the code encompasses both white coat hypertension and masked hypertension.

Neither will ABPM code choice: The good news is that there “will be more opportunities to have ABPM covered under Medicare, since coverage is expanding from white coat hypertension to add masked hypertension,” says Moore.

However, “CPT^® coding for ABPM will not change,” Moore continues, though you will still need to be vigilant with your code choices. Not only does the NCD’s device criteria specify that the monitor has to be able “to produce standardized plots of blood pressure measurements for 24 hours,” but also “you will need to make sure that they are coding for the correct component of monitoring based on recording vs. analysis vs. interpretation and report,” according to Johnson.

This means if you are providing the global service (i.e. all components), the CPT^® code you report will be 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). However, if you are only providing one component of the covered ABPM, you would report the code corresponding with that component, including:

• 93786 (… recording only)
• 93788 (… scanning analysis with report)
• 93790 (… review with interpretation and report).

NCD dictates documentation: Even though your coding won’t change, you should still go back to the NCD to make sure you documented the services correctly. First, and most important, you will have to make sure your provider has used an ABPM device that can not only produce the previously mentioned standardized blood pressure measurement plots over the 24-hour period, but also that nighttime and daytime measurements are delineated. Additionally, you will need to provide evidence that your provider’s practice has demonstrated how to use the ABPM device to the patient. And, as previously noted, the documentation will need to include your provider’s interpretation.

The final word: Lastly, the determination notes that Medicare will cover ABPM for eligible patients only once per year. So, you will not be able to bill it more than once during that time.

For more information view the whole NCD at www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=294.