Primary Care Coding Alert

Question: A patient came in and picked up our 24-hour blood pressure monitor. He came back the following day to return it. The report reads “recorded on 05/21/2019, read back on 05/22/2019.” Which date should we use for the date of service (DOS), and what codes should we use to document it?

Codify Subscriber

Answer: As the patient used the monitor on 5/21, and the report notes that your provider reviewed the data on 5/22, you would give 5/22 as the DOS.

The correct CPT^® code for the service would 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). As the code’s descriptor states, the service is all-inclusive, incorporating the patient’s recording of the data and your provider’s analysis, interpretation, and report.

Should your provider only perform parts of the service, you would use other codes. Possibilities include:

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

You will need to link these services to an appropriate ICD-10 code, which will depend on the specifics of the patient’s condition. If the patient does not have a diagnosis, you could use a signs and symptoms code from the R03.- (Abnormal blood-pressure reading, without diagnosis) group or even R55 (Syncope and collapse), subject to the provider’s note, to justify the monitoring.

Additionally, depending on the results, you would use either Z01.30 (Encounter for examination of blood pressure without abnormal findings) or Z01.31 (Encounter for examination of blood pressure with abnormal findings). Note that if you use Z01.31, you should use an additional code to identify the abnormal findings in question.