Primary Care Coding Alert

Question: Aetna considers 24-hour blood pressure (BP) monitoring experimental and/or investigational and denies the service. Should I appeal that decision?

New Mexico Subscriber

Answer: You should appeal the decision if your patient meets the insurer's medical-necessity requirements. Aetna considers ambulatory blood pressure monitoring (ABPM, 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; 93788, ... scanning analysis with report; or 93790, ... physician review with interpretation and report) a noncovered service in several situations, such as routine monitoring to diagnose hypertension or to evaluate BP treatment responses.

The insurer, however, will reimburse ABPM if the FP suspects that the patient may have one of three hypertension types: white coat, resistant or episodic. Aetna also covers ABPM of patients who have hypotensive symptoms or nocturnal angina or require syncope evaluation with a Holter monitor. If your FP orders ABPM for an Aetna member that meets one of the above criteria, make sure he documents all supporting information.

Aetna, for example, only covers suspected white-coat hypertension (796.2, Elevated blood pressure reading without diagnosis of hypertension) if the patient has repeated blood pressure systolic readings of 140 to 150 mm Hg and/or diastolic readings of 90 to 99 mm Hg. Plus, Aetna requires that the FP can't definitively diagnose hypertension despite all of the following:

a. The physician has performed at least three in-office blood pressure measurements at least one week apart

b. Nonphysicians have obtained mild hypertensive readings from the patient

c. The member has repeated at-home blood pressure measurements over at least one month.

To view Aetna's ABPM policy, visit the Web site  www.Google.com. Enter "Aetna + blood pressure monitoring" in the search engine and click on "Aetna: Automated Ambulatory Blood Pressure Monitoring."