Medical Policy Bulletin

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Title:

Ambulatory Blood Pressure Monitoring (ABPM)

Policy #:

07.02.09

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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the medical necessity criteria for ambulatory blood pressure monitoring. For information on policies related to this topic, refer to the Cross References Table in this policy.

Description:

Ambulatory blood pressure monitoring (ABPM) involves the use of a noninvasive device that measures blood pressure in 24-hour cycles. The device consists of a portable sphygmomanometer attached to a recording device. The information it provides can help a physician determine whether an individual is truly hypertensive or is exhibiting white coat hypertension (WCH). WCH is a condition characterized by persistently raised blood pressure in the doctor's office with a normal ambulatory blood pressure. WCH is defined as blood pressure greater than 140/90 mm Hg on at least three clinic/office visits with two separate measurements made at each visit, and blood pressure less than 140/90 mm Hg documented on at least two separate blood pressure measurements taken outside the office. The ABPM device is fitted to and removed from the individual by a trained technician. The sphygmomanometer inflates at predetermined times, generally every 30 minutes, and the blood pressure recorded at each inflation is stored. The individual performs normal activities while wearing the monitor. Automated ABPM is considered more accurate than individual self-monitoring. Therefore, it is generally thought that readings obtained at frequent intervals throughout the day and night would help the physician better manage the individual's care. These stored 24-hour measurements are later interpreted at the physician’s office. A clinician is required to interpret the collected data by uploading it onto a computer where device-specific programs are used to categorize and analyze the measurements.

Policy

Ambulatory blood pressure monitoring (ABPM) is considered medically necessary and, therefore, covered for individuals who meet the definition criteria of White Coat Hypertension (WCH) and have no evidence of end-organ damage. ABPM is covered for individuals requiring 24-hour monitoring of their blood pressure to confirm the diagnosis. Physician interpretation is medically necessary and required for reimbursement. Therefore, ABPM utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer, with recording only or scanning analysis with report only (no mention of physician interpretation), is not eligible for separate reimbursement when billed alone or in conjunction with another service.

Guidelines

In the rare circumstance that ambulatory blood pressure monitoring (ABPM) needs to be performed more than once on an individual, the qualifying criteria as described in the policy must be met for each subsequent ABPM test. When a primary care physician (PCP) is contracted to provide medically necessary and preventive care services on a monthly capitation basis, this service is included in the monthly capitation payment. Eligible codes are reimbursable only with the diagnosis codes listed in the coding table. Claims submitted for any diagnoses not listed in the coding table are denied as not medically necessary. MEDICARE This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare. US FOOD AND DRUG ADMINISTRATION (FDA) The FDA has approved several ambulatory blood pressure monitoring units and considers these devices to be Class II devices, which are exempt from premarket notification procedures.

References

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 20.19: Ambulatory blood pressure monitoring. [CMS Web site]. 07/01/03. Available at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20.19&ncd_version=2&show=all. Accessed January 27, 2009.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	TO REPORT ABPM USE, USE THE FOLLOWING CODES: 93784, 93790 THE FOLLOWING CODES ARE NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT AS THESE SERVICES DO NOT INCLUDE A PHYSICIAN COMPONENT: 93786, 93788
ICD Procedure	N/A
ICD Diagnosis	796.2: Elevated blood pressure reading without diagnosis of hypertension
HCPCS Level II	N/A
Revenue Codes	N/A

Cross References

Version Effective Date: 10/25/2004