CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Ambulatory Blood Pressure Monitoring (ABPM) Coverage Criteria

Policy governs coverage of 24-hour fully automated ambulatory blood pressure monitoring for commercial members of Blue Cross Blue Shield - Rhode Island, primarily to evaluate suspected white coat hypertension; excludes BlueCHiP for Medicare (see related policy).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAmbulatory Blood Pressure Monitoring (ABPM) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 12, 2016

Next Review Date

Key ActionVerify benefits and perform ABPM once to differentiate suspected white coat hypertension when office BP is <180/110 mm Hg and no end-organ damage is present.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-hourmonitoring duration described

1 timeappropriate frequency

93784-93790covered codes

A4670excluded device code

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAmbulatory Blood Pressure Monitoring (ABPM) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJan 12, 2016

Next Review Date

Key ActionVerify benefits and perform ABPM once to differentiate suspected white coat hypertension when office BP is <180/110 mm Hg and no end-organ damage is present.

SourceLink

On This Page

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Indication: Patient has suspected white coat hypertension (elevated office blood pressure with suspected normal out-of-office readings)

Office BP severity: Office blood pressure elevation is in the mild-to-moderate range and less than 180/110 mm Hg (not requiring immediate medication treatment)<180/110 mm Hg

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

Frequency: Procedure performed one time to differentiate white coat hypertension from true hypertension1 time

Not medically necessary

ABPM is considered not medically necessary for the following uses:

Not covered uses: Repeated testing in patients with persistently elevated office blood pressure; monitoring of treatment effectiveness; other uses for elevated office blood pressure beyond single differentiation of white coat hypertension

Evidence insufficient to determine effects on health outcomes

Coding

Covered CPT/HCPCS CodesCPTCovered

93784	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; including recording, scanning analysis, interpretation and report.
93786	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; recording only.
93788	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; scanning analysis with report.
93790	Ambulatory blood pressure monitoring, utilizing report-generating software, automated, worn continuously for 24 hours or longer; review with interpretation and report.

Not coveredHCPCSNot Covered

A4670

Automatic blood pressure monitor

Supported ICD-10 Diagnosis CodesICD-10

I10	Essential (primary) hypertension
I11.0-I11.9	Hypertensive heart disease range
R03.0	Elevated blood-pressure reading, without diagnosis of hypertension
Z01.30-Z01.31	Encounter for examination of blood pressure without abnormal findings / with abnormal findings (range provided in policy)

Office BP level for appropriateness

Office BP threshold<180/110 mm Hg

Appropriate frequencyOne time to differentiate WCH from sustained hypertension

Context for thresholdMild-to-moderate elevation not requiring immediate medication treatment

Provider Actions & Billing

Prior Authorization

Prior authorization — No prior authorization required for ABPM.

Note

Benefits & Coverage

Benefits vary by contract — verify beneficiary's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable benefits and coverage (some groups may have different not medically necessary provisions).

Billing Rule

Operational / Billing Instructions

Operational/billing instructions — ABPM should be performed with a fully automated monitor worn continuously for 24 hours or longer and billed using covered CPT codes (93784, 93786, 93788, 93790). A patient-level rule: use ABPM one time to differentiate suspected white coat hypertension from sustained hypertension; use for repeated testing in patients with persistently elevated office BP or for routine monitoring of treatment effectiveness is considered not medically necessary.

Covered CPT: 93784, 93786, 93788, 93790
Not covered HCPCS: A4670 (automatic blood pressure monitor)
Clinical note: ABPM typically performed continuously for 24 hours or longer with report-generating software

Background

Ambulatory blood pressure monitoring (ABPM) uses a fully automated, portable monitor worn by the patient that records blood pressure at preprogrammed intervals over a 24-hour period while the patient carries out normal activities. Obtaining multiple automated readings over 24 hours reduces the variability inherent in single office measurements, provides information on circadian blood pressure patterns, and can improve the accuracy of hypertension diagnosis—most commonly to evaluate suspected white coat hypertension where office readings are elevated but out-of-office readings may be normal.

OpenPayer

Ambulatory Blood Pressure Monitoring (ABPM) Coverage Criteria

Coverage Criteria

Coding

Provider Actions & Billing

Background

Definitions