ABPM Reimbursement

Reimbursements are an important consideration in deciding when and how to incorporate ABPM as part of a practice.  ABPM is reimbursable by Medicare as well as private carriers, with reimbursements ranging from $59 to $98 for Medicare and $50 to $300 for private payers.  As with other procedures, reimbursement rates vary based on a number of factors including geography, insurance company policies as well as patient conditions.

Medicare

Medicare covers ABPM for those patients with suspected White Coat Hypertension (ICD-9 796.2), and requires documentation in the patient's chart that their blood pressure was elevated on at least three separate clinic/office visits, with two separate measurements made at each visit. In addition, there should be at least two measurements taken outside of the office. Finally, there should be no evidence of end-organ damage.

Please refer to the CMS National Cover Decision as well as Updated Policy and Claims Instructions for further information.

Private Insurance Carriers

As can be expected, private carriers are more generous in their reimbursements and will reimburse for a wider range of indications, including resistant hypertension, episodic hypertension, arrhythmia, evaluation of syncope, and gestational hypertension/preeclampsia. Of course, not all carriers cover all conditions.

The following are some estimates of reimbursement rates.  Click on links to see the payer's specific policies.

Carrier Reimbursement Range
Aetna $170-$200
Cigna $160-$300
Blue Cross/Blue Sheild 1 2 $60-$80
First Health $170-$190
Pacificare $180-$210
United Healthcare $55-$60

Again, the coverage decisions and reimbursement rates vary by carrier, contractual agreements, and for each state. While many private carriers deem ABPM to be an effective and economical method of diagnosis, some carriers (for instance Blue Cross/Blue Shield companies in certain regions) do not view ABPM as a medical necessity. Please contact your billing department, IPA, or your carrier representative for your contracted rates.

Please make sure to visit our ABPM coding information page to properly document each ABPM procedure.  Finally, in case you receive a denial letter, please contact us for a sample appeal letter requesting reconsideration of such a decision.

 

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