Part B Insider (Multispecialty) Coding Alert

Published on Fri Nov 18, 2005 PDF

Key:  ICD-9 code 796.2 can get you $67

The code you report for ambulatory blood pressure monitoring (ABPM) will determine whether or not Medicare will cover the service. Here's the skinny on how you can secure payment--and how white-coat hypertension (WCH) testing comes into play.  

"Medicare is very black and white on its ABPM's diagnosis requirements," says Maria M. Torres, CPC, CMM, with Bermudez Medical Consulting in Tampa, FL. National Medicare policy only accepts 796.2 (Elevated blood pressure reading without diagnosis of hypertension), according to Medlearn Matters article MM2726.

Key: Medicare's coverage will depend on the internist's testing for WCH and whether or not Medicare feels the procedure is medically necessary. To qualify for WCH, the physician must document the following:

• in-office BP readings greater than 140/90 mm Hg on at least three separate visits with the nurse or other staff member taking two separate measurements at each visit;

• at least two documented separate BP measurements less than 140/90 mm Hg, taken by an appropriate non-office source (e.g., a paramedic, a nurse at a health fair, or validated measurements at a pharmacy); and

• no evidence of end-organ damage (for example, kidney or heart problems related to hypertension).

Remember: If a Medicare patient doesn't satisfy the 796.2 diagnosis, the patient should sign an advanced beneficiary notice (ABN). Yet, if Medicare deems the ABPM is medically necessary, it will pay about $67 locally for the test.

Caution: Once you've chosen your CPT and ICD-9 codes, you're not finished. Medicare imposes test-related requirements on ABPM claims. The testing must satisfy three criteria:

1. The test is an outpatient service (hospital inpatients and residential institution patients do not qualify for coverage).

2. The device monitors the patient's ambient blood pressure for at least 24 hours.

3. The internist interprets the ABPM results.

Editor's Note: To read the CMS Medlearn Matters' article on ABPM, download the document from www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM2726.pdf.