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National Coverage Determination (NCD)

Ambulatory Blood Pressure Monitoring

50-42

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Tracking Information

Publication Number
6
Manual Section Number
50-42
Manual Section Title
Ambulatory Blood Pressure Monitoring
Version Number
1
Effective Date of this Version
04/01/2002
Ending Effective Date of this Version
07/01/2003
Implementation Date
04/01/2002
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Tests (other)


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Ambulatory blood pressure monitoring (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 at the physician's office.
Indications and Limitations of Coverage

ABPM must be performed for at least 24 hours to meet coverage criteria.

ABPM is only covered for those patients with suspected white coat hypertension. Suspected white coat hypertension is defined as 1) 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 blood pressure measurements taken outside the office which are <140/90 mm Hg; and 3) no evidence of end-organ damage. The information obtained by ABPM is necessary in order to determine the appropriate management of the patient. ABPM is not covered for any other uses. In the rare circumstance that ABPM needs to be performed more than once in a patient, the qualifying criteria described above must be met for each subsequent ABPM test.

For those patients that undergo ABPM and have an ambulatory blood pressure of <135/85 with no evidence of end-organ damage, it is likely that their cardiovascular risk is similar to that of normotensives. They should be followed over time. Patients for which ABPM demonstrates a blood pressure of >135/85 may be at increased cardiovascular risk, and a physician may wish to consider antihypertensive therapy.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
149
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R149CIM.pdf
Revision History

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)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Ambulatory Blood Pressure Monitoring 3 07/02/2019 - N/A View
Ambulatory Blood Pressure Monitoring 2 07/01/2003 - 07/02/2019 View
Ambulatory Blood Pressure Monitoring 1 04/01/2002 - 07/01/2003 You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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