Jun 2002 Table of Contents

GETTING PAID

New Medicare Payment Opportunities



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Here's how to get paid for ambulatory blood pressure monitoring and medical nutrition therapy.

Fam Pract Manag. 2002 Jun;9(6):18.

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Medicare has expanded its coverage in recent months to include ambulatory blood pressure monitoring (ABPM) and medical nutrition therapy (MNT) for patients with diabetes or renal disease. Here's how to take advantage of these new reimbursement options.

Blood pressure monitoring

ABPM involves the use of a non-invasive device to measure blood pressure in 24-hour cycles. The device automatically takes the patient's blood pressure at intervals set by the physician. These 24-hour measurements are stored in the device and are later interpreted at the physician's office.

ABPM must be performed for at least 24 hours to meet Medicare coverage criteria, and it is only covered for those patients with suspected white-coat hypertension, which Medicare defines as follows:

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

  • At least two documented blood pressure measurements taken outside the office that are <140/90 mm Hg;

  • No evidence of end-organ damage.

Although there are four CPT codes related to ABPM, only three of them are covered by Medicare:

  • When you provide both the technical and professional components, use code 93784.

  • When you provide the technical component only, use 93786.

  • When you provide the professional component only, use 93790.

The Medicare allowed amount (for participating physicians, not adjusted for geography) $43.08, $34.03, and $9.05, respectively.

Medical nutrition therapy

Medicare coverage has also been extended to pay for MNT for beneficiaries with diabetes or renal disease. The law defines MNT services as “nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a registered dietitian (RD) or nutrition professional … pursuant to a referral by a physician….”

For both renal disease and diabetes, Medicare will provide a total of three hours of basic coverage in the year of diagnosis and two hours per year in subsequent years. Only the number of hours of basic coverage per year is restricted. The referring physician will be free to determine the exact length and number of the visits as long as the yearly limit is not exceeded.

Also, additional hours will be considered medically necessary and covered if the treating physician determines there is a change in medical condition, diagnosis or treatment regimen that requires a change in MNT and thus orders additional hours during that episode of care.

Examples for diabetes include but are not limited to the following:

  • A beneficiary converting from oral medication to insulin,

  • A beneficiary with gestational diabetes requiring frequent dietary modification.

Examples for renal disease include but are not limited to the following:

  • A beneficiary experiencing a clinically significant decrease in renal efficiency,

  • A beneficiary demonstrating a lack of understanding of the renal diet.

Finally, if the treating physician determines that receipt of both services is medically necessary, Medicare will cover both diabetes self-management training (DSMT) and MNT in initial and subsequent years without decreasing either benefit as long as DSMT and MNT are not provided on the same dates of service.

MNT provided by an RD or nutrition professional should be billed using one of the following three codes:

  • 97802, “initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes,”

  • 97803, “re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes,”

  • 97804, “group (2 or more individual(s)), each 30 minutes.”

Per CPT, MNT assessment and/or intervention done by a physician should be coded using a preventive medicine or other evaluation and management code. Medicare is consistent with CPT in this regard because the law defines MNT for Medicare purposes as being provided by an RD or nutrition professional.

Want to know more?

For more information, see the Medicare Coverage Issues Manual (www.hcfa.gov/pubforms/06_cim/ci50.htm#_50_42), which addresses ABPM, or www.hcfa.gov/coverage/8b3-ggg2.htm regarding MNT.

Kent Moore is the AAFP's manager for health care financing and delivery systems and is a contributing editor to FPM.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.


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