CMS Pub. 100-04, ch. 32, § 10.1

A. Coding Applicable to A/B MACs (A and B)

Effective April 1, 2002, a National Coverage Decision was made to allow for Medicare coverage of ABPM for

those beneficiaries with suspected "white coat hypertension" (WCH). ABPM involves the use of a non-invasive

device, which is used to measure blood pressure in 24-hour cycles. These 24-hour measurements are stored in the

device and are later interpreted by a physician. Suspected "WCH" is defined as: (1) Clinic/office blood pressure

>140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit;

(2) At least two documented separate blood pressure measurements taken outside the clinic/office which are <

140/90 mm Hg; and (3) No evidence of end-organ damage. ABPM is not covered for any other uses. Coverage

policy can be found in Medicare National Coverage Determinations Manual, Chapter 1, Part 1,

§20.19. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).

The ABPM must be performed for at least 24 hours to meet coverage criteria. Payment is not allowed for

institutionalized beneficiaries, such as those receiving Medicare covered skilled nursing in a facility. In the rare

circumstance that ABPM needs to be performed more than once for a beneficiary, the qualifying criteria described

above must be met for each subsequent ABPM test.

Effective dates for applicable Common Procedure Coding System (HCPCS) codes for ABPM for suspected

WCH and their covered effective dates are as follows:

HCPCS Definition Effective

Date

93784 ABPM, utilizing a system such as magnetic tape and/or

computer disk, for 24 hours or longer; including

recording, scanning analysis, interpretation and report.

04/01/2002

93786 ABPM, utilizing a system such as magnetic tape and/or

computer disk, for 24 hours or longer; recording only.

04/01/2002

93788 ABPM, utilizing a system such as magnetic tape and/or

computer disk, for 24 hours or longer; scanning analysis

with report.

01/01/2004

HCPCS Definition Effective

Date

93790 ABPM, utilizing a system such as magnetic tape and/or

computer disk, for 24 hours or longer; physician review

with interpretation and report.

04/01/2002

In addition, one of the following diagnosis codes must be present:

Diagnosis

Code

Description

If ICD-10-

CM

is

applicable

R03.0 Elevated blood pressure reading without diagnosis of

hypertension

B. A/B MAC (A) Billing Instructions

The applicable types of bills acceptable when billing for ABPM services are 13X, 23X, 71X, 73X, 75X, and 85X.

Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B

MACs (A). The A/B MACs (A) pay for hospital outpatient ABPM services billed on a 13X type of bill with

HCPCS 93786 and/or 93788 as follows: (1) Outpatient Prospective Payment System (OPPS) hospitals pay based

on the Ambulatory Payment Classification (APC); (2) non-OPPS hospitals (Indian Health Services Hospitals,

Hospitals that provide Part B services only, and hospitals located in American Samoa, Guam, Saipan and the

Virgin Islands) pay based on reasonable cost, except for Maryland Hospitals which are paid based on a percentage

of cost. Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for

ABPM.

The A/B MACs (A) pay for comprehensive outpatient rehabilitation facility (CORF) ABPM services billed on a

75x type of bill with HCPCS code 93786 and/or 93788 based on the Medicare Physician Fee Schedule (MPFS)

amount for that HCPCS code.

The A/B MACs (A) pay for ABPM services for critical access hospitals (CAHs) billed on a 85x type of bill as

follows: (1) for CAHs that elected the Standard Method and billed HCPCS code 93786 and/or 93788, pay based on

reasonable cost for that HCPCS code; and

(2) for CAHs that elected the Optional Method and billed any combination of HCPCS codes 93786, 93788 and

93790 pay based on reasonable cost for HCPCS 93786 and 93788 and pay 115% of the MPFS amount for HCPCS

93790.

The A/B MACs (A) pay for ABPM services for skilled nursing facility (SNF) outpatients billed on a 23x type of

bill with HCPCS code 93786 and/or 93788, based on the MPFS.

The A/B MACs (A) accept independent and provider -based rural health clinic (RHC) bills for visits under the all-inclusive rate when the RHC bills on a 71x type of bill with revenue code 052x for providing the professional

component of ABPM services. The A/B MACs

(A) should not make a separate payment to a RHC for the professional component of ABPM services in addition to

the all-inclusive rate. RHCs are not required to use ABPM HCPCS codes for professional services covered under

the all-inclusive rate.

The A/B MACs (A) accept free-standing and provider-based federally qualified health center (FQHC) bills for

visits under the all-inclusive rate when the FQHC bills on a 73x type of bill with revenue code 052x for providing

the professional component of ABPM services.

The A/B MACs (A) should not make a separate payment to a FQHC for the professional component of ABPM

services in addition to the all-inclusive rate. FQHCs are not required to use ABPM HCPCS codes for professional

services covered under the all-inclusive rate.

The A/B MACs (A) pay provider-based RHCs/FQHCs for the technical component of ABPM services when billed

under the base provider’s number using the above requirements for that particular base provider type, i.e., a OPPS

hospital based RHC would be paid for the ABPM technical component services under the OPPS using the APC for

code 93786 and/or 93788 when billed on a 13x type of bill.

Independent and free-standing RHC/FQHC practitioners are only paid for providing the technical component of

ABPM services when billed to the A/B MAC (B) following the MAC’s instructions.

• A/B MAC (B) Claims

A/B MACs (B) pay for ABPM services billed with ICD -10-CM diagnosis code R03.0 (if ICD -10 is applicable)

and HCPCS codes 93784 or for any combination of 93786, 93788 and 93790, based on the MPFS for the specific

HCPCS code billed.

• Coinsurance and Deductible

The A/B MACs (A and B) shall apply coinsurance and deductible to payments for ABPM services except for services

billed to the A/B MAC (A) by FQHCs. For FQHCs only coinsurance applies.

11 - Wound Treatments

(Rev 124a, 03-19-04)