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Date Printed: August 22, 2017: 07:13 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-93875-16

Original Effective Date: 01/01/89

Reviewed: 09/22/16

Revised: 10/15/16

Subject: Ambulatory Blood Pressure Monitoring (ABPM) for Diagnosis of Hypertension in Members With Elevated Office Blood Pressure

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Ambulatory blood pressure monitoring (ABPM), typically done over a 24-hour period with a fully automated device, provides more detailed blood pressure (BP) information than readings typically obtained during office visits. The greater number of readings with ABPM improves the variability of single BP measurements and is more representative of the circadian rhythm of BP compared with the limited number obtained during office measurement.

There are a number of potential applications of ABPM. One of the most common is evaluating suspected white coat hypertension (WCH), which is defined as an elevated office BP with normal BP readings outside the physician’s office. The etiology of WCH is poorly understood but may be related to an “alerting" or anxiety reaction associated with visiting the physician's office.

In assessing patients with elevated office BP, ABPM is often intended to identify those with normal ambulatory readings who do not have sustained hypertension. Because this group of patients would otherwise be treated based on office BP readings alone, ABPM could improve outcomes by allowing these patients to avoid unnecessary treatment. However, this assumes patients with WCH are not at increased risk for cardiovascular events and would not benefit from antihypertensive treatment.

POSITION STATEMENT:

Automated ambulatory blood pressure monitoring over a 24-hour period with an FDA approved device meets the definition of medical necessity for members with elevated office blood pressure (BP), when performed 1 time to differentiate between “white coat hypertension” and true hypertension, when ALL of the following conditions are met:

Office BP elevation is in the mild-to-moderate range (<180/110), not requiring immediate treatment with medications;

There is an absence of hypertensive end-organ damage on physical examination and laboratory testing.

All other uses of ambulatory blood pressure monitoring for members with elevated office BP, including but not limited to repeated testing in members with persistently elevated office BP, and monitoring of treatment effectiveness, is considered experimental or investigational. The evidence is insufficient to determine the effects of the technology on health outcomes.

Note: Per USPSTF Screening for High Blood Pressure in Adults Grade A recommendation: Ambulatory blood pressure monitoring can be used to confirm a diagnosis of hypertension after initial screening.

BILLING/CODING INFORMATION:

The following codes may be used to describe ambulatory blood pressure monitoring.

CPT Coding:

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

HCPCS Coding:

A4670

Automatic blood pressure monitor

REIMBURSEMENT INFORMATION:

Ambulatory blood pressure monitoring is limited to one (1) in twelve (12) months. In the rare circumstances that ABPM needs to be performed more than once in a member, the qualifying criteria must be met for each subsequent ABPM test.

NOTE: Services in excess of the limitations shown above (e.g. repeat study for follow-up) are subject to medical review of documentation for determination of medical necessity. The following information may be required documentation to support medical necessity: physician history and physical, conservative treatment plan, physician progress notes, and all laboratory studies.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Chemistry Studies (i.e., fasting blood glucose, serum BUN, creatinine, sodium, potassium, calcium, blood hematocrit, lipid profile, albumin/creatinine ratio)

19011-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, Discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Medication Current

19009-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Urinalysis Studies

18729-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Ambulatory Blood Pressure Monitoring (20.19) located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

01-99385-03, Preventive Services

OTHER:

None applicable.

REFERENCES:

  1. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Developed in Collaboration With the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension
  2. American Heart Association, Out-O-Office Blood Pressure Readings Help Predict CVD Risk, 12/04.
  3. Berg A, Allan J et al. U.S. Preventative Services Task Force, Guidelines from Guide to Clinical Preventative Services: Third Edition (2000-2003) June 1, 2003.
  4. Blue Cross Blue Shield Association Medical Policy Reference Manual – 1.01.02, Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients With Elevated Office Blood Pressure, 07/16.
  5. Blue Cross Blue Shield Association Technology Evaluation Center, “Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Adults,” (06/99; updated 2001).
  6. Centers for Medicare & Medicaid Services, NCD for Ambulatory Blood Pressure Monitoring (20.19), 07/01/03; accessed at cms.gov 08/22/16.
  7. Chobanian A, Bakris G et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The JNC 7 Report. JAMA. 2003; 289:2560-2572.
  8. ClinicalTrials.gov:
  9. Ambulatory Blood Pressure Monitoring in the Prediction of Cardiovascular Events and Effects of Chronotherapy (MAPEC; ClinicalTrials.gov Identifier: NCT00295542
  10. Ambulatory Blood Pressure Monitoring in Hypertension; ClinicalTrials.gov Identifier: NCT00166634
  11. Ambulatory Blood Pressure Monitoring for Antihypertensive Treatment Guidance; ClinicalTrials.gov Identifier: NCT00139984
  12. ECRI Institute, Continuous Ambulatory Blood Pressure [CABP] Monitoring, 06/07.
  13. Florida Medicare Part B Local Coverage Determination #93784 – “Ambulatory Blood Pressure Monitoring (ABPM)”, (RETIRED 05/01/04).
  14. HAYES Medical Technology Directory – “Ambulatory Blood Pressure Monitoring with Fully Automatic Portable Monitors” (12/04/04), 11/06 update.
  15. Medicare Coverage Issues Manual (CIM 50-42 – Ambulatory Blood Pressure Monitoring), (01/16/03).
  16. Medicare Decision Memorandum re: National Coverage Policy Revision – AB-01-188, Change Request 1985 – “Coverage and Billing of Ambulatory Blood Pressure Monitoring (ABPM)”, (12/18/01).
  17. Medicare Decision Memorandum Transmittal 168 – Change Request 2625 – “Coverage and Billing of Ambulatory Blood Pressure Monitoring (ABPM)”, (dated 03/28/03).
  18. National Institute for Health and Clinical Excellence. Hypertension: clinical management of primary hypertension in adults. NICE clinical guideline 127. Accessed 01/03/12.
  19. Palmas W, Pickering TG, Teresi J, Schwartz JE, Moran A, Weinstock RS, Shea S. Ambulatory blood pressure monitoring and all-cause mortality in elderly people with diabetes mellitus. Hypertension. 2009 Feb;53 (2):120-7. Epub 2009 Jan 5.
  20. Piper MA, et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. Feb 3 2015;162(3):192-204.
  21. U.S. Preventive Services Task Force (USPSTF), Screening for High Blood Pressure, accessed at uspreventiveservicestaskforce.org 08/22/16.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/22/16.

GUIDELINE UPDATE INFORMATION:

01/01/89

Medical Coverage Guideline secondary to BCA TEC in 1988 – investigational.

06/15/02

Reformatted & revised – investigational – Medicare coverage added.

05/15/03

Reviewed; no change (investigational).

07/15/04

Scheduled review and revision; consisting of updated references and added coverage statement with set criteria.

08/15/05

Scheduled review and revision; consisting of updated references.

09/15/07

Review; coverage statement maintained, guideline reformatted, and updated references.

07/15/11

Revision; formatting changes.

03/15/12

Review; Position Statement and Reimbursement section revised, references updated; formatting changes.

01/01/13

Annual HCPCS coding update; revised descriptor for 93790

05/11/14

Revision: Program Exceptions section updated.

08/15/16

Revision; note added to position statement section and references updated.

10/15/16

Revision; title, description, position statements, coding, and references updated.

Date Printed: August 22, 2017: 07:13 AM