Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
Policy #:MA07.005c

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

AMBULATORY BLOOD PRESSURE MONITORING

MEDICALLY NECESSARY
Ambulatory blood pressure monitoring (ABPM) for a 24-hour period or longer is considered medically necessary and, therefore, covered for individuals who meet the following criteria and there is an absence of hypertensive end-organ damage on physical examination and appropriate laboratory testing:
  • Suspected white coat hypertension demonstrated by the following:
    • The individual has an average office blood pressure of systolic blood pressure greater than 130 mmHg but less than 160 mmHg or diastolic blood pressure greater than 80 mmHg but less than 100 mmHg on two separate clinic/office visits, with two separate measurements made at each visit, and blood pressure less than 130/80 mmHg documented on at least two separate blood pressure measurements taken outside the office.
  • Suspected masked hypertension demonstrated by the following:
    • The individual has an average office blood pressure between 120 mmHg and 129 mmHg for systolic blood pressure or between 75 mmHg and 79 mmHg for diastolic blood pressure on two separate clinic/office visits with at least two separate measurements made at each visit and with at least two blood pressure measurements taken outside the office which are ≥130/80 mmHg.

ABPM devices must meet all of the following specifications:
  • Must be capable of producing standardized plots of blood pressure measurements for 24 hours with daytime and night-time windows and normal blood pressure bands demarcated;
  • Must be provided to individuals with oral and written instructions and a test run in the professional provider's office must be performed;
  • Must have output interpreted by the treating professional provider.

NOT MEDICALLY NECESSARY
All other uses for ABPM are considered not medically necessary and, therefore, not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

HOME BLOOD PRESSURE MONITORING DEVICES

MEDICALLY NECESSARY
Non-automatic home blood pressure monitoring (HBPM) devices are considered medically necessary and, therefore, covered for individuals with end-stage renal disease who are receiving home dialysis.

NOT MEDICALLY NECESSARY
All other uses for non-automatic HBPM devices are considered not medically necessary and, therefore, not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

NON-COVERED
An automatic HBPM (A4670) device is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

REPLACEMENT HOME BLOOD PRESSURE MONITORING DEVICES
The Company may determine the reasonable useful lifetime of a specific non-automatic HBPM device based on the manufacturer's recommendation.

In the absence of manufacturer's recommendations, the Company may determine the reasonable useful lifetime of a non-automatic HBPM device, but is generally not less than five years. Replacement of one or more of its components (parts) that are necessary for its proper functioning due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include, but are not limited to, records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, ambulatory blood pressure monitoring (ABPM) is covered under the medical benefits of the Company's Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Subject to the terms and conditions of the applicable Evidence of Coverage, non-automatic home blood pressure monitoring (HBPM) devices are covered under the medical benefits of the Company’s Medicare Advantage products when the criteria listed in this policy are met. However, services that are identified in this policy as not covered are not eligible for coverage or reimbursement by the Company.

Description

AMBULATORY BLOOD PRESSURE MONITORING (24-HOUR SPHYGMOMANOMETER)

Ambulatory blood pressure monitoring (ABPM) involves the use of a noninvasive device that measures blood pressure in 24-hour cycles (24 hour sphygmomanometer). The device consists of a portable sphygmomanometer attached to a recording device. The ABPM device is fitted to and removed from the individual by a trained technician. The sphygmomanometer inflates at predetermined times, generally every 30 minutes, and the blood pressure recorded at each inflation is stored. The individual performs normal activities while wearing the monitor. The device provides information about blood pressure during daily activities, as well as during sleep.

Ambulatory blood pressure monitoring is considered more accurate than individual self-monitoring. Therefore, it is generally thought that readings obtained at frequent intervals throughout the day and night would help the professional provider better manage the individual's care. These stored, 24-hour measurements are later interpreted at the professional provider’s office. A clinician is required to interpret the collected data by uploading it onto a computer where device specific programs are used to categorize and analyze the measurements.

The information that ABPM provides, for example, can help a professional provider determine whether an individual is truly hypertensive or is exhibiting white coat hypertension (WCH). WCH is a condition characterized by persistently raised blood pressure in the doctor's office with a normal ambulatory blood pressure. WCH is defined as blood pressure greater than 130/80 mmHg on at least three clinic/office visits, with two separate measurements made at each visit, and blood pressure less than 130/80 mmHg documented on at least two separate blood pressure measurements taken outside the office.

HOME BLOOD PRESSURE MONITORING DEVICES

Blood pressure management using HBPM, is an important component for risk management in individuals with end-stage renal disease (ESRD). Hypertension is highly prevalent among individuals who have ESRD requiring dialysis or a kidney transplant.

The two main types of home blood pressure monitoring (HBPM) devices are non-automatic and automatic (or electronic). Many of these devices are available for retail purchase, and some have undergone technical validation according to recommended protocols.
References

Agena F, Prado Edos S, PS, et al. Home blood pressure (BP) monitoring in kidney transplant recipients is more adequate to monitor BP than office BP. Nephrol Dial Transplant. 2011;26(11):3745-9.

Centers for Medicare and Medicaid Services (CMS).CMS Manual System. Medicare Claims Processing. Transmittal 109. [CMS Web site]. 02/27/2004. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R109CP.pdf. Accessed August 26, 2019.

Centers for Medicare and Medicaid Services (CMS). Decision memo for ambulatory blood pressure monitoring (ABPM) (CAG-00067R2). 07/02/2019. Available at:https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=294. Accessed on August 26, 2019.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 11: End stage renal disease (ESRD). 20.4: Renal dialysis items and services: Eequipment and supplies. [CMS Web site] 01/01/2015. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c11.pdf. Accessed August 26, 2019.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 20.19: Ambulatory blood pressure monitoring. [CMS Web site]. 07/01/2003. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=254&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d&. Accessed August 26, 2019.

Evidence of Coverage.

James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA.2014;311(5):507-520.
Malliara M. The management of hypertension in hemodialysis and continuous ambulatory peritoneal dialysis (CAPD) patients. Hippokratia. 2007;11(4):171-174.

National Heritage Insurance Company (NHIC). Noncovered items. [NHIC Web site]. 02/20/2017. Available at: https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. Accessed August 26, 2019.

O'Brien E, Parati G, Stergiou G. Ambulatory blood pressure measurement: What is the international consensus? Hypertension. 2013;62:988-994.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

93784, 93786, 93788, 93790


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

AMBULATORY BLOOD PRESSURE MONITORING (93784, 93786, 93788, 93790) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

R03.0 Elevated blood-pressure reading, without diagnosis of hypertension



HOME BLOOD PRESSURE MONITORING DEVICES (A4660, A4663) ARE MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

N18.6 End stage renal disease

Z99.2 Dependence on renal dialysis




HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

A4660 Sphygmomanometer/blood pressure apparatus with cuff and stethoscope=

A4663 Blood pressure cuff only

NOT COVERED

A4670 Automatic blood pressure monitor




Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA07.005c:
04/08/2020The policy has been reviewed and reissued to communicate the Company’s continuing position on Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices.
01/01/2020This policy has been identified for the CPT code update, effective 01/01/2020.

The following narratives have been revised in this policy: 93784, 93786, 93788, 93790.

MA07.005b:
10/21/2019This version of the policy will become effective 10/21/2019.

This policy has been updated to communicate expanded national coverage of Ambulatory Blood Pressure Monitoring (ABPM) by the Centers for Medicare and Medicaid Services (CMS) to include suspected masked hypertension; blood pressure threshold for hypertension was lowered.

MA07.005a:
05/08/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices.
06/06/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices.
03/29/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) devices.
08/01/2016This version of the policy will become effective 08/01/2016.

This policy has been updated to communicate the following:
  • Current white coat hypertension (WCH) criteria qualified for ambulatory blood pressure monitoring (ABPM) services
  • The Company’s continuing position on home blood pressure monitoring (HBPM) devices
  • Replacement criteria for non-automatic HBPM devices

The following ICD-10 CM codes have been added to this policy: I12.0, I13.11, I13.2, N18.6, Z99.2.

The following HCPCS codes have been added to this policy: A4660, A4663, A4670 (non-covered).


MA07.005
02/04/2015The policy has been reissued to communicate the Company’s continuing position on Ambulatory Blood Pressure Monitoring (ABPM).
01/01/2015This is a new policy.





Version Effective Date: 01/01/2020
Version Issued Date: 01/03/2020
Version Reissued Date: 04/08/2020