NCD 20.19

Item/Service Description

A. General

Ambulatory Blood Pressure Monitoring (ABPM) is a diagnostic test that allows for the identification of various types of high blood pressure (BP). ABPM devices are small portable machines that are connected to a blood pressure cuff worn by patients that record blood pressure at regular periods over 24 to 48 hours while the patient goes about their normal activities, including sleep. The recording is interpreted by a physician or non-physician practitioner, and appropriate action is taken based on the findings. Diagnosis and treatment of high BP is important for the management of various conditions including cardiovascular disease and kidney disease.

Indications and Limitations of Coverage

B. Nationally Covered Indications

For dates of service on and after July 2, 2019, the Centers for Medicare & Medicaid Services (CMS) believes that the evidence is sufficient to determine that ABPM is reasonable and necessary for the diagnosis of hypertension in Medicare beneficiaries under the following circumstances:

• For beneficiaries with suspected white coat hypertension, which is defined as average office BP of systolic BP > 130 mm Hg but < 160 mm Hg, or diastolic BP > 80 mm Hg but < 100 mm Hg on two separate clinic/office visits with at least two separate measurements made at each visit, and with at least two BP measurements taken outside the office which are < 130/80 mm Hg.

• For beneficiaries with suspected masked hypertension, which is defined as average office BP between 120 mm Hg and 129 mm Hg for systolic BP, or between 75 mm HG and 79 mm Hg for diastolic BP on two separate clinic/office visits with at least two separate measurements made at each visit, and at least two BP measurements taken outside the office which are &ge; 130/80 mm Hg.

ABPM devices must be:

• capable of producing standardized plots of BP measurements for 24 hours with daytime and night-time windows and normal BP bands demarcated; and,

• provided to patients with oral and written instructions and a test run in the physician’s office must be performed; and,

• interpreted by the treating physician or treating non-physician practitioner.

For eligible patients, ABPM is covered once per year.

C. Nationally Non-Covered Indications

N/A

D. Other

Coverage of other indications for ABPM not indicated above are at the discretion of the Medicare Administrative Contractors.

(Last reviewed July 2019.)

Revision History

05/2020 - The purpose of this change request is to inform contractors that for dates of service on and after July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring for the diagnosis of hypertension in Medicare beneficiaries under updated criteria. (TN 10073) (CR11650)

11/2016 - This change request (CR) is the 9th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, CR9252, CR9540, and CR9631. Some are the result of revisions required to other NCD-related CRs released separately.

Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. (TN 1753) (CR9751)

08/2016 - This change request (CR) is the 9th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, CR9252, CR9540, and CR9631. Some are the result of revisions required to other NCD-related CRs released separately.

Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process. (TN 1708) (CR9751)

09/2012 - CMS translated the information for this policy from ICD-9-CM/PCS to ICD-10-CM/PCS according to HIPAA standard medical data code set requirements and updated any necessary and related coding infrastructure. These updates do not expand, restrict, or alter existing coverage policy.Implementation date: 01/07/2013 Effective date: 10/1/2015. (TN 1122) (TN 1122) (CR 7818)

03/2003 - Specified physician is required to perform interpretation of data obtained through ABPM, but no requirements regarding setting where interpretation performed. Effective and implementation dates 07/01/2003. (TN 168) (CR 2625)

12/2001 - Changed status from non-covered to covered and clarified conditions under which ABPM is covered. Effective and implementation dates 04/01/2002. (TN 149) (CR 1985)