CMS Reconsiders “White Coat Hypertension” Limitation
Is ambulatory blood pressuring monitoring reasonable and necessary for people with masked hypertension?
It has been 18 years since the Centers for Medicare & Medicaid Services (CMS) issued the National Coverage Determination (NCD) for Ambulatory Blood Pressure Monitoring (ABPM) (20.19). At the time, ABPM wasn’t even considered for patients diagnosed with hypertension. As such, Medicare coverage for this service is limited to patients with suspected “white coat hypertension,” who are not being treated for high blood pressure. CMS is proposing to update the NCD to expand coverage for ABPM in patients with suspected “masked hypertension.”
Up for Discussion
In a proposed decision memo, issued April 9, CMS says that sufficient evidence now exists to determine that ABPM is reasonable and necessary for the diagnosis and management of hypertension in Medicare patients with either:
- Suspected white coat hypertension – when a patient’s anxiety from being in a clinical setting causes their blood pressure to rise uncharacteristically – defined as office blood pressure ≥130/80 mm Hg and <160/100 mm Hg on at least two separate clinic/office visits with two separate measurements made at each visit after 3 months of behavioral interventions including diet and exercise modification and with at least two blood pressure measurements taken outside the office which are <130/80 mm Hg; or
- Suspected masked hypertension – when a patient’s blood pressure is much lower at a clinic in comparison to readings at home – defined as office blood pressure between 120 and 130/80 mm Hg on at least two separate clinic/office visits with two separate measurements made at each visit after 3 months of behavioral interventions including diet and exercise modification and at least two blood pressure measurements taken outside the office which are ≥130/80 mm Hg.
Note that the proposed decision includes lowering the blood pressure threshold from 140/90 to 130/80 to align with the latest society recommendations for hypertension criteria.
For eligible patients, ABPM is covered once per year for suspected white coat hypertension and, upon finalizing the decision memo, masked hypertension. Coverage for other indications for ABPM is at the discretion of the Medicare Administrative Contractor.
APBM Coverage Parameters
ABPM measures blood pressure at regular intervals (typically every 15-30 minutes) throughout the day and night, according to the Preventive Cardiovascular Nurses Association (PCNA), to acquire a true or mean blood pressure in patients with suspected white coat hypertension or suspected masked hypertension.
CMS requires ABPM devices to be:
- Quality-certified and validated for use in the intended patient population by a CMS-approved quality control organization;
- Capable of producing standardized plots of blood pressure measurements for 24 hours with daytime and nighttime windows and normal blood pressure bands demarcated;
- Provided to patients with oral and written instructions and a test run in the physician’s office must be performed; and
- Read by the treating physician or non-physician practitioner.
A diagnosis of white coat hypertension is reported with ICD-10-CM code R03.0 Elevated blood pressure reading, without diagnosis of hypertension. If CMS removes the requirement that there be no evidence of end-organ damage, a diagnosis code for hypertension will also support ABPM.
Report ABPM with the applicable CPT or HCPCS Level II code:
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 Ambulatory blood pressure monitoring utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only
93788 Ambulatory blood pressure monitoring utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report
93790 Ambulatory blood pressure monitoring utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; review with interpretation and report
A4670 Automatic blood pressure monitor
The Final Word
CMS is seeking comments on the proposed decision memo through May 8. A final decision is expected by July 8. The effective date of coverage will be announced in a CMS transmittal shortly thereafter.
Update: 05/2020 – For dates of service on and after July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring for the diagnosis of hypertension in Medicare beneficiaries under updated criteria. (TN 10073) (CR11650)
CMS Newsroom, April 9, 2019
PCNA, Ambulatory Blood Pressure Monitory for the Clinician