7-step SMBP quick guide: Coding

As of Jan. 1, 2020, physicians can submit claims for SMBP services using Current Procedural Terminology (CPT®) codes 99473 and 99474.

The codes address both initial and ongoing SMBP clinical services:

CPT code 99473

CPT code 99473 can be used when a patient receives education and training (facilitated by clinical staff) on the set-up and use of a SMBP measurement device validated for clinical accuracy, including device calibration.

99473 can only be used once per device. It would most commonly be used prior to initiating SMBP in patients suspected of having hypertension or for those patients with an existing diagnosis of hypertension who have a new BP measurement device or are receiving training for the first time.

CPT code 99474

CPT code 99474 can be used for SMBP data collection and interpretation when patients use a BP measurement device validated for clinical accuracy to measure their BP twice daily (two measurements, one minute apart in the morning and evening), with a minimum of 12 readings required each billing period.

The SMBP measurements must be communicated back to the practice and can be manually recorded (e.g., phone, fax or in-person) or electronically captured and transmitted (e.g., secure e-mail, patient portal, or directly from device).

The physician or other qualified health care professional must then create or modify the treatment plan based on the documented average of these readings. The treatment plan must be documented in the medical record and communicated back to the patient, either directly or through clinical staff.

Coding limitations for CPT codes 99474 and 99473

99474 can be submitted once per calendar month; it cannot be used in the same calendar month as codes for ambulatory blood pressure monitoring (93784, 93786, 93788, 93790), remote physiologic monitoring (99453-8, 99091) or chronic care management 99487, 99489-91).

99473 can be submitted once per device, 99473 and 99474 should not be reported if performed as part of an E/M service. A separately reportable E/M service should be provided with Modifier 25.

Other CPT codes that can be used for SMBP are found in the digitally stored data/remote physiologic monitoring section of the CPT code set. Remote physiologic monitoring (RPM) codes are for collecting and interpreting physiologic data that is digitally stored and/or transmitted by the patient and/or caregiver to the physician or qualified health care professional.

Parameters for CPT codes 99453-99458

Requirement:

• A physician or qualified health care professional must prescribe RPM and a medical device (as defined by the FDA) to be used for conducting RPM.
• Patients must consent to enroll in RPM (patients may incur a co-pay for services, typically 20% of RPM charges per month for Medicare) and consent must be documented.
• If a patient has not been seen in the practice for one year or is a new patient, Medicare may require a face-to-face encounter before billing for RPM.
• Monitoring must occur for at least 16 days within a month.
• Data must be digitally stored and/or transmitted back to the physician or other qualified health professional.
• Interactive communication between the physician/other qualified health professional and patient and/or caregiver is required, although an interactive video connection is not needed.

Coding limitations for CPT code 99457

99457 may not be billed together with 99091 for same billing period and beneficiary.

Parameters for CPT code 99091

Requirement:

• Requires a minimum of 30 minutes of care team time spent toward services in each 30-day period.
• Patients must consent to enroll in RPM and consent must be documented.
• The number of monitoring days required per month is not specified.
• Data must be digitally stored and electronically transferred back to the practice.

Coding limitations for CPT code 99091

• If an E/M service occurs on the same day, 99091 should not be reported separately.
• 99091 may not be billed together with 99457 for the same billing period and beneficiary.
• The code cannot be reported if it occurs within 30 days of codes 99339, 99340, 99374-9 or 99457.

RPM services can overlap with chronic care management (CCM) services and both codes can be used within a calendar month. RPM may also be billed in the same calendar month as transitional care management services and behavioral health integration services. However, the time spent performing RPM must be separate from the time spent on CCM, transitional care management or behavioral health integration services.

The guide highlights seven key steps physicians and care teams can take to use SMBP with patients 18 years and older with high blood pressure, and includes links to useful supporting resources.

1. SMBP training video
2. SMBP training video (Spanish)
3. SMBP infographic (PDF)
4. SMBP infographic (Spanish) (PDF)
5. SMBP recording log (PDF)
6. SMBP CPT® coding
7. SMBP Coverage Insights: Medicaid (PDF)
8. SMBP Policy Brief: Medicaid (PDF)
9. SMBP benefits for patients with Medicaid

Disclaimer: Information provided by the AMA contained within this Guide is for medical coding guidance purposes only. It does not (i) supersede or replace the AMA’s Current Procedural Terminology® manual (“CPT Manual”) or other coding authority, (ii) constitute clinical advice, (iii) address or dictate payer coverage or reimbursement policy, and (iv) substitute for the professional judgement of the practitioner performing a procedure, who remains responsible for correct coding.

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