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US CMS Reimbursement FAQs
Medical insurance reimbursement is an important issue for all medical diagnostic tests. The following are frequently asked questions about reimbursement details in the USA.
ABPM
Q. For what indication(s) does Medicare reimburse for ABPM?
A. Diagnosis of suspected white coat hypertension only, with physician guidelines developed by HCFA/CMS.
Q. What is the definition of white-coat hypertension?
A. Suspected WCH is defined as office Blood Pressure greater than 140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit. In addition, there should be at least two BP measurements taken outside the office which are less than 140/90 mm Hg. There should be no evidence of end-organ damage.
Q. What is the amount of reimbursement?
A. The amount of reimbursement can vary by region. It is important that you contact your Medicare contractor to verify reimbursement amounts for your region.
Q. What are the Current Procedural Terminology (CPT) codes for ABPM?
A. The CPT codes for ABPM are as follows:
- CPT 93784 - Ambulatory Blood Pressure Monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer, including recording, scanning analysis, interpretation and report.
- CPT 93786 - Recording only
- CPT 93790 - Interpretation only
- CPT 93788 - Scanning analysis with report
For more information, see our CMS reimbursement page.
Q. When billing Medicare what ICD-9 code should be used?
A. For billing Medicare, 796.2 is the appropriate ICD-9 code.
Please contact us with any further questions concerning SunTech or our products.
Cardiovascular/Exercise Stress Test
Q. For what indications does Medicare reimburse for a Cardiovascular/Exercise Stress Test?
A. The indications are as follows:
- To determine the location, presence and severity of exercise induced myocardial ischemia
- Evaluate potential for rhythm disturbances
- Evaluate hemodynamic responses to activity
- Evaluate the effect of medical or interventional therapy
- Prescribe appropriate activity guidelines
- Pre-operative evaluation of patients at high risk for coronary artery disease who are scheduled to undergo general anesthesia and/or undergo a surgical procedure which places them at risk for a sudden cardiac event.
- Establish prognosis and management decisions following an uncomplicated myocardial infarction.
- Determine whether underlying coronary artery disease is the etiology of unexplained left ventricular dysfunction
- Assess for recurrent ischemia in patients with prior percutaneious intervention who are at increased risk for restenosis.
Q. What is the amount of reimbursement?
A. The rates for reimbursement can vary by geographical region, insurance company policies, and patient conditions. It is important that you contact your Medicare contractor to verify reimbursement amounts for your region.
Q. What are the CPT codes for Exercise Stress Testing?
A. To view the CPT codes for reimbursement, please click here.
Pulse Oximetry
Q. For what indications does Medicare reimburse for Pulse Oximetry?
A. Medicare will allow a separate payment for oximetry when medically necessary to evaluate conditions which are commonly associated with oxygen desaturation:
- The patient exhibits signs or symptoms of acute respiratory dysfunction (tachypnea; dyspnea; cyanosis; respiratory distress; confusion; hypoxia; severe chest pain)
- The patient has chronic lung disease, chest trauma, severe cardiopulmonary disease, or neuron-muscular disease involving the muscles of respiration, and oximetry is needed for evaluation of the patient's condition.
- The patient is under treatment with a medication with known pulmonary toxicity.
Q. What is the amount of reimbursement?
A. The rates for reimbursement can vary by geographical region, insurance company policies, and patient conditions. It is important that you contact your Medicare contractor to verify reimbursement amounts for your region.
Q. What are the CPT codes for Pulse Oximetry?
A. To view the CPT codes for reimbursement, please click here.
Reimbursement Information for ABPM
ABPM is currently reimbursable by both Medicare and private insurance providers. Global reimbursement rates generally vary between $62–$122 for Medicare and $75–$300 for private insurance carriers. Rates for reimbursement rates vary depending on geographical region, insurance company policies and patient conditions
Medicare currently only reimburses ABPM for patients with suspected "white coat" hypertension. This requires the patient meeting a set of qualifying criteria. For more information, please view Medicare's most recent statement on policy and instructions for ABPM reimbursement.
What are the applicable CPT codes and clinical indications for ABPM?
| CPT Codes | |
|---|---|
| 93784 | Global Code. ABPM utilizing a system (such as Oscar 2) for 24 hours or longer, including recording, scanning analysis, interpretation and report. |
| 93786 | Recording only. |
| 93788 | Scanning analysis with report. |
| 93790 | Physician review with interpretation and report |
| ICD-9 Codes | |
|---|---|
| 796.2 | ONLY code reimbursed by Medicare. Elevated blood pressure reading without diagnosis of hypertension. |
| 401 | Essential hypertension |
| 401.1 | Benign hypertension |
| 401.9 | Unspecified hypertension - (Resistant) |
| 402 | Hypertensive heart disease |
| 402.1 | Benign hypertensive heart disease |
| 402.10 | Benign hypertension without congestive |
| 402.9 | Unspecified hypertensive heart disease |
| 402.90 | Unspecified hypertension without congestive heart failure |
| 403 | Hypertensive renal disease |
| 413 | Nocturnal angina |
| 429 | Ill-defined descriptions and complications of heart disease |
| 458 | Orthostatic hypotension |
| 458.9 | Unspecified hypotension |
| 642 | Hypertension complicating pregnancy, childbirth and puerperium |
| 642.3 | Transient hypertension of pregnancy |
| 642.4 | Mild or unspecified preeclampsia |
| 642.9 | Unspecified hypertension complicating pregnancy |
| 669.2 | Maternal hypotension syndrome |
| 780.2 | Syncope and collapse |
| 997.91 | Other hypertension - episodic |
Reimbursement Information for Tango+
Applicable CPT codes and clinical indications for Exercise Stress Test
| CPT Codes | |
|---|---|
93015 | Cardiovascular stress test using maximal or sub maximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report. |
93016 | Physician supervision only, without interpretation and report |
93017 | Tracing only, without interpretation and report |
93018 | Interpretation and report only |
J0150 | Injection, Adenosine, per 6 mg |
J0152 | Injection, Adenosine for diagnostic use, 90 mg |
J1245 | Injection, Dipyridamole (Persantine), per 10 mg |
J1250 | Injection, Dobutamine, per 250 mg |
| ICD-9 Codes | |
|---|---|
394.0-394.9 | Diseases of mitral valve |
395.0-395.9 | Diseases of aortic valve |
396.0-396.9 | Diseases of mitral and aortic valves |
402.00-402.91 | Hypertensive heart disease |
404.00-404.93 | Hypertensive heart and kidney disease |
410.00-410.92 | Acute myocardial infarction |
411.0-411.89 | Other acute and subacute forms of ischemic heart disease |
412 | Old myocardial infarction |
413.0-413.9 | Angina pectoris |
414.00-414.9 | Other forms of chronic ischemic heart disease |
416.0 – 416.9 | Chronic pulmonary heart disease |
424.0-424.3 | Other diseases of endocardium |
425.0-425.9 | Cardiomyopathy |
426.0-426.9 | Conduction disorders |
427.0-427.9 | Cardiac dysrhythmias |
428.0-428.9 | Heart failure |
429.0-429.9 | Ill defined descriptions and complications of heart disease |
780.2 | Syncope and collapse |
780.4 | Dizziness and giddiness |
785.50 | Shock without mention of trauma |
785.51 | Cardiogenic shock |
785.52 | Septic shock |
786.02 | Orthopnea |
786.05 | Shortness of breath |
786.50-786.59 | Chest pain |
794.31 | Abnormal electrocardiogram |
996.72 | Other complications of cardiac device or graft |
996.83 | Complication of transplanted heart |
V15.1 | Personal history of surgery to heart and great vessels |
V42.1 | Heart replaced by transplant |
V42.2 | Heart valve replaced by transplant |
V42.6 | Lung replaced by transplant |
V43.4 | Heart valve replaced by other means |
Applicable CPT codes and clinical indications for Pulse Oximetry
| CPT Codes | |
|---|---|
94760 | Noninvasive ear or pulse oximetry for oxygen saturation; single determination |
96761 | Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise). |
| ICD-9 Codes | |
|---|---|
011.00-011.96 | Tuberculosis of lung infiltrative confirmation unspecified – unspecified pulmonary tuberculosis tubercle bacilli not found by bacteriological histological examination but tuberculosis confirmed by other methods. |
020.3-020.5 | Primary pneumonic plague – pneumonic plague unspecified |
021.2 | Pulmonary tularemia |
039.1 | Pulmonary actinomycotic infection |
052.1 | Varicella (hemorrhagic pneumonitis) |
073.0 | Ornithosis with pneumonia |
079.82 | SARS-associated coronavirus infection |
130.4 | Pneumonitis due to toxoplasmosis |
135 | Sarcoidosis |
136.3 | Pneumocystosis |
162.0-162.9 | Malignant neoplasm of trachea – malignant neoplasm of bronchus and lung unspecified |
163.0 – 163.9 | Malignant neoplasm of pleura |
197.0 | Secondary malignant neoplasm of lung |
277.00 | Cystic fibrosis without meconium ileus |
277.01 | Cystic fibrosis with meconium ileus |
277.02 | Cystic fibrosis with pulmonary manifestations |
277.03 | Cystic fibrosis with gastrointestinal manifestations |
277.09 | Cystic fibrosis with other manifestations |
289.0 | Polycythemia secondary |
293.0 | Delirium due to conditions classified elsewhere |
327.09 | Other organic insomnia |
327.21 | Primary central sleep apnea |
327.23 | Obstructive sleep apnea (adult) (pediatric) |
327.29 | Other organic sleep apnea |
335.20 | Amyotrophic lateral sclerosis |
357.0 | Acute infective polyneuritis |
358.00 | Myasthenia gravis without (acute) exacerbation |
358.01 | Myasthenia gravis with (acute) exacerbation |
391.8 | Other acute pneumatic heart disease |
392.0 | Rheumatic chorea with heart involvement |
398.91 | Rheumatic heart failure (congestive) |
402.01 | Malignant hypertensive heart disease with heart failure |
402.11 | Benign hypertensive heart disease with heart failure |
402.91 | Unspecified hypertensive heart disease with heart failure |
404.91 | Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease Stage I through Stage IV, or unspecified |
404.93 | Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease Stage V or end stage renal disease |
415.0 | Acute cor pulmonale |
415.11 | Iatrogenic pulmonary embolism and infarction |
415.12 | Septic pulmonary embolism |
416.0 | Primary pulmonary hypertension |
416.9 | Chronic pulmonary heart disease unspecified |
427.89 | Other specified cardiac dysrhythmias |
428.0 | Congestive heart failure unspecified |
428.1 | Left heart failure |
428.20-428.23 | Unspecified systolic heart failure – acute on chronic systolic heart failure |
428.30-428.33 | Unspecified diastolic heart failure – acute on chronic diastolic heart failure |
428.40-428.43 | Unspecified combined systolic and diastolic heart failure – acute on chronic combined systolic and diastolic heart failure |
428.9 | Heart failure unspecified |
464.51 | Supraglottitis unspecified with obstruction |
466.0-466.19 | Acute bronchitis – acute bronciolitis due to other infectious organisms |
478.30-478.34 | Unspecified paralysis of vocal cords – complete bilateral paralysis of vocal cords |
478.6 | Edema of larynx |
478.70 | Unspecified disease of larynx |
478.71 | Cellulitis and perichondritis of larynx |
478.74 | Stenosis of larynx |
478.75 | Laryngeal spasm |
478.79 | Other diseases of larynx |
478.8 | Upper respiratory tract hypersensitivity reaction site unspecified |
480.0 | Pneumonia due to adenovirus |
480.1 | Pneumonia due to respiratory syncytial virus |
480.2 | Pneumonia due to parainfluenza virus |
480.3 | Pneumonia due SARS-associated coronavirus |
480.8 | Pneumonia due to other virus not elsewhere classified |
480.9 | Viral pneumonia unspecified |
481 | Pneumococcal pneumonia (streptococcus pneumoniae pneumonia) |
482.1 | Pneumonia due to pseudomonas |
482.30-482.39 | Pneumonia due to streptococcus unspecified – pneumonia due to other streptococcus |
482.40 | Pneumonia due to staphylococcus unspecified |
482.41 | Pneumonia due to staphylococcus aureus |
482.49 | Other staphylococcus pneumonia |
482.81-482.89 | Pneumonia due to anaerobes – pneumonia due to other specified bacteria |
483.0-483.8 | Pneumonia due to mycoplasma pneumoniae – pneumonia due to other specified organism |
484.1-484.8 | Pneumonia in cytomegalic inclusion disease – pneumonia in other infectious diseases classified elsewhere. |
485 | Bronchopneumonia organism unspecified |
486 | Pneumonia organism unspecified |
487.0 | Influenza with pneumonia |
487.1 | Influenza with other respiratory manifestations |
488 | Influenza due to identified avian influenza virus |
490 | Bronchitis not specified as acute or chronic |
491.1 | Mucopurulent chronic bronchitis |
491.20-491.21 | Obstructive chronic bronchitis without exacerbation – obstructive chronic bronchitis with (acute) exacerbation |
491.8 | Other chronic bronchitis |
491.9 | Unspecified chronic bronchitis |
492.0 | Emphysematous bleb |
492.8 | Other emphysema |
493.00-493.01 | Extrinsic asthma unspecified – extrinsic asthma with status asthmaticus |
493.10-493.11 | Intrinsic asthma unspecified – intrinsic asthma with status asthmaticus |
493.20-493.21 | Chronic obstructive asthma unspecified – chronic obstructive asthma with status asthmaticus |
493.81 | Exercise-induced bronchospasm |
493.82 | Cough variant asthma |
493.90-493.91 | Asthma unspecified – asthma unspecified type with status asthmaticus |
494.0-494.1 | Bronchiectasis without acute exacerbation – bronchiectasis with acute exacerbation |
495.0-495.9 | Farmers’ lung – unspecified allergic alveolitis and pneumonitis |
496 | Chronic airway obstruction not elsewhere classified |
500 | Coal workers’ pneumoconiosis |
501 | Asbestosis |
502 | Pneumoconiosis due to other silica or silicates |
503 | Pneumoconiosis due to other inorganic dust |
504 | Pneumonopathy due to inhalation of other dust |
505 | Pneumoconiosis unspecified |
506.0-506.9 | Bronchitis and pneumonitis due to fumes and vapors – unspecified respiratory conditions due to fumes and vapors |
507.0-507.8 | Pneumonitis due to inhalation of food or vomitus – pneumonitis due to other solids and liquids |
508.0-508.9 | Acute pulmonary manifestations due to radiation – respiratory conditions due to unspecified external agent |
510.0-510.9 | Empyema with fistula – empyema without fistula |
511.0-511.9 | Pleurisy without effusion or current tuberculosis – unspecified pleural effusion |
512.0-512.8 | Spontaneous tension pneumothorax – other spontaneous pneumothorax |
513.0-513.1 | Abscess of lung – abscess of mediastinum |
514 | Pulmonary congestion and hypostasis |
515 | Postinflammatory pulmonary fibrosis |
516.0-516.9 | Pulmonary alveolar proteinosis – unspecified alveolar and parietoalveolar pneumonopathy |
517.1 | Rheumatic pneumonia |
517.2 | Lung involvement in systemic sclerosis |
517.3 | Acute chest syndrome |
519.4 | Disorders of diaphragm |
710.1 | Systemic sclerosis |
714.81 | Rheumatoid lung |
748.61 | Congenital bronchiectasis |
780.01-780.09 | Coma – alteration of consciousness other |
780.39 | Other convulsions |
780.51 | Insomnia with sleep apnea, unspecified |
780.53 | Hypersomnia with sleep apnea, unspecified |
780.57 | Unspecified sleep apnea |
782.5 | Cyanosis |
785.0 | Tachycardia unspecified |
785.50 | Shock unspecified |
785.51 | Cardiogenic shock |
785.52 | Septic shock |
785.59 | Other shock without trauma |
786.00-786.09 | Respiratory abnormality unspecified – respiratory abnormality other |
786.3 | Hemoptysis |
786.50-786.59 | Unspecified chest pain – other chest pain |
786.6 | Swelling mass or lump in chest |
793.1 | Nonspecific abnormal findings on radiological and other examination of lung field |
799.01-799.1 | Asphyxia - respiratory |
807.4 | Flail chest |
958.7 | Traumatic subcutaneous emphysema |
987.9 | Toxic effect of unspecified gas fume or vapor |
997.3 | Respiratory complications not elsewhere classified |
998.81 | Emphysema (subcutaneous) (surgical) resulting from procedure |
V01.82 | Exposure to SARS-associated coronavirus |
V42.6 | Lung replaced by transplant |
V58.69 | Long-term (current) use of other medications |
V67.2 | Follow-up examination following chemotherapy |
