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National Coverage Determination (NCD)

Ambulatory Blood Pressure Monitoring

20.19

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Tracking Information

Publication Number
100-3
Manual Section Number
20.19
Manual Section Title
Ambulatory Blood Pressure Monitoring
Version Number
3
Effective Date of this Version
07/02/2019
Ending Effective Date of this Version
Implementation Date
06/16/2020
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

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:

  1. 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.
  2. 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 ≥ 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.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
10073
Coverage Transmittal Link
https://www.cms.gov/files/document/R10073NCD.pdf
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)
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 You are here
Ambulatory Blood Pressure Monitoring 2 07/01/2003 - 07/02/2019 View
Ambulatory Blood Pressure Monitoring 1 04/01/2002 - 07/01/2003 View
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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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