Internal Medicine Coding Alert

Published on Mon Jun 14, 2004 PDF

Why assigning 796.2 is key for Medicare claims

You can get paid for the internist's ambulatory blood pressure monitoring (ABPM) if you know which blood-pressure diagnosis code to use, the three requirements your patient must meet to receive these services, and the differences among codes 93784-93790.

Physicians use ABPM to evaluate the patient's ambient blood pressure during a 24-hour period, says Lisa Barnes, a coder with Fayetteville Diagnostic Clinic, an Arkansas multi-specialty practice that includes internists. Atechnician attaches the blood pressure monitor to the patient. The device obtains blood pressure measurements and records them on either magnetic tape or a computer disk, she adds.

Medicare requirement: CMS designates ABPM as an outpatient service. Hospitals and residential institutions, such as SNFs, cannot bill for the service.

1. Understand 'White-Coat' Hypertension

When the physician provides ABPM (93784-93790) to a Medicare patient, make sure the doctor is testing for "white-coat" hypertension. Otherwise, Medicare and some private carriers won't reimburse you.

Patients with white-coat hypertension have high blood pressure readings in the doctor's office, but normal readings in other settings. With ABPM, physicians coder can measure and observe fluctuations in the patient's blood pressure over 24 hours. The results let the doctor know whether the patient has hypertension or if being in a doctor's office causes the high blood pressure.

Medicare accepts only diagnosis code 796.2 (Elevated blood pressure reading without diagnosis of hypertension) when the physician uses ABPM to test for white-coat hypertension, says Pat Larabee, CPC, CCP, a coding specialist at InterMed, a multi-specialty healthcare network in South Portland, Maine. "Our commercial carriers are a little more lenient" regarding the ICD-9 codes they will take, she adds.

For example, private insurer Aetna in Hartford, Conn., pays for ABPM when the patient has, or the physician suspects the patient has, one of the following conditions:

Resistant hypertension: A secondary form of hypertension, this condition usually develops in hypertension (401.0x) patients who are unresponsive to medications.

Hypotensive or syncopal symptoms: Typically, these conditions occur in patients with adverse reactions to anti-hypertension medications. The patients may develop low blood pressure or faint.

Nocturnal angina: You may bill Aetna for ABPM when the physician investigates blood pressure changes in patients with nocturnal angina (413.0, Angina decubitus). Patients with this condition have severe chest pains while recumbent.

Episodic hypertension: Apatient may develop episodic hypertension as a secondary reaction to an adrenal tumor (for example, pheochromocytoma). Usually office blood pressure measurements come back normal.

2. Learn Which Codes Represent ABPM Services

If your internist is billing Medicare for ABPM, you have to link 796.2 to the appropriate codes from the 93784-93790 series. Each code in the series represents different ABPM-related services. For instance, you would assign different codes for interpretation and scanning analysis.

Review the following CPT descriptors and coding advice to a get grip on reporting 93784-93790:

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.

Coding advice: You should use this code for the complete ABPM procedure, including physician interpretation and report, Barnes says.

93786 -- ... recording only.

Coding advice: Assign 93786 when the internist bills only for the device that records the blood-pressure measurements and records them on magnetic tape, Barnes advises. Remember that this code does not include any physician interpretation or report, she adds.

93788 -- ... scanning analysis with report.

Coding advice: This year, Medicare began paying for 93788, which you should list for the internist's scanning analysis and report of ABPM procedures. But be careful: Some local Medicare carriers may not have updated their coverage policies to meet the new Medicare guidelines. Therefore, check with your local payer to ensure coverage.

93790 - ... physician review with interpretation and report.

Coding advice: You should report 93790 for the internist's interpretation and report, Barnes says. In other words, this code represents the physician's professional services, not the technical services (for example, recording only).

Important: The National Correct Coding Initiative (NCCI) edits, version 10.0, indicate that you cannot report 93784 with any of the lesser ambulatory monitoring services (93786-93790). Also, you can't unbundle the codes with a modifier, such as -59 (Distinct procedural service).

3. Follow 4 Criteria for Medical Necessity

In addition to supplying 796.2 for Medicare patients, you also have to prove that the patient meets Medicare's criteria for white-coat hypertension. If the patient doesn't meet the criteria, you won't get paid for 93784-93790.

Your documentation should contain these four criteria:

1. The patient's blood pressure level was greater than 140/90 on at least three separate office visits, with the physician or other medical staff taking two separate measurements at each visit.
2. At least two separate blood pressure measurements came back at less than 140/90, which a physician or nurse took outside the office.
3. The patient has no evidence of end-organ damage (for example, kidney or heart problems directly related to hypertension).
4. The physician must interpret the data he obtained through the ABPM.