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Overview

SMBP overview image of a man in glasses testing his blood pressure

Defining self-measured blood pressure

Self-measured blood pressure (SMBP) refers to blood pressure (BP) measurements obtained outside of a physician's practice or clinical setting, usually at home. When combined with clinical support (e.g., one-on-one counseling, web-based or telephonic support tools, education), SMBP can help enhance the quality and accessibility of care for people with high blood pressure and improve blood pressure control.1

SMBP can be used to assess BP control and aid in diagnosing of hypertension. SMBP allows patients to actively participate in the management of their BP and has been shown to improve adherence to antihypertensive medications.1 It is recommended to be used in conjunction with telehealth counseling or clinical interventions for the titration of BP-lowering medication.2

The recent COVID-19 pandemic has led to a rapid increase in the use of telemedicine by many health care organizations. physicians and care teams. Using telemedicine modalities with self-measured blood pressure (SMBP) can help patients with hypertension achieve and maintain blood pressure goals.2

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References

1 Centers for Disease Control and Prevention. Self-measured blood pressure monitoring: Actions steps for clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2014.

2 Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA guideline for the prevention, detection, evaluation and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19).
   

Download the 7-step SMBP quick guide

Our 7-step SMBP quick guide is a reference for physicians and care teams to help train patients to perform SMBP monitoring.

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Disclaimer: These steps are for informational purposes only. These steps are not intended as a substitute for the medical advice of a physician; they offer no diagnoses or prescription. Furthermore, this information should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, nor exclusive of other methods of care reasonably directed to obtaining the same results. This protocol reflects the best available evidence at the time that it was prepared. The results of future studies may require revisions to the recommendations in this protocol to reflect new evidence, and it is the clinician's responsibility to be aware of such changes.

7 steps

Helping patients achieve and maintain blood pressure goals

There are over 115 million adults in the United States with hypertension, many of whom have uncontrolled hypertension.1 These patients are at higher risk for heart attacks, strokes, heart failure, kidney disease and peripheral vascular disease, and would benefit from continued monitoring and treatment of  their hypertension, regardless of whether the care is provided virtually or in-person.2

This 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. Identify patients for SMBP

—Patients with an existing diagnosis of hypertension

—Patients with high pressure without a diagnosis of hypertension

—Patients suspected of having hypertension (labile or masked hypertension)

2. Confirm device validation and cuff size

—Make sure patients have automated, validated devices with appropriately sized upper arm cuffs

3. Train patients

—Educate patients on how to perform SMBP using an evidence-based measurement protocol, and education should include proper preparation, proper positioning before taking measurements and resting one minute between measurements

—Verify patients’ understanding and share educational resources

Tools

SMBP training video

SMBP training video (Spanish)

SMBP infographic (PDF)

SMBP infographic (Spanish, PDF)
    

4. Have patients perform SMBP

—Conduct SMBP monitoring whenever BP assessment is desired (e.g., to confirm a diagnosis, to assess every 2-4 weeks if BP is uncontrolled or at physician discretion) 

—Provide instructions on the duration of monitoring and the number of measurements to take each day
    —7 days of monitoring recommended; 3 days (i.e., 12 readings) minimum
    —Measurements should be taken twice daily (morning and evening) with at least two measurements taken each time

—Determine when and how patients will share results back to care team
    —Examples include phone, portal or secure messaging

5. Average results

—Average all SMBP measurements received from patients for monitoring period

—Document average systolic and average diastolic blood pressure in medical record
    —Use the average systolic and average diastolic blood pressure for clinical decision making
    —Three days of measurements (i.e., 12 readings) are recommended as a minimum for clinical decision-making

6. Interpret results

—Make diagnosis and/or assess control

—Initiate, intensify or continue treatment as needed

To view the SMBP interpretation tables, go to the "Interpret results" tab of this page.

 

7. Document plans and communicate to patients

—Document treatment and follow-up plans and communicate to patients

—Confirm patients' agreement and understanding

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References

1 Virani SS. Alonso A. Benjamin EJ. et al, on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020:141:e139-e596. doi: 10.1161/CIR.0000000000000757.

2 Whelton PK, Carey RM, Aronow WS. Casey DE Jr. Collins KJ, Dennison Himmelfarb C. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMNPCNA guideline for the prevention, detection. evaluation. and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018:71(19).
  

Download the 7-step SMBP quick guide

Our 7-step SMBP quick guide is a reference for physicians and care teams to help train patients to perform SMBP monitoring.

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Disclaimer: These steps are for informational purposes only. These steps are not intended as a substitute for the medical advice of a physician; they offer no diagnoses or prescription. Furthermore, this information should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, nor exclusive of other methods of care reasonably directed to obtaining the same results. This protocol reflects the best available evidence at the time that it was prepared. The results of future studies may require revisions to the recommendations in this protocol to reflect new evidence, and it is the clinician's responsibility to be aware of such changes.

Ensure accuracy

Helping patients obtain accurate SMBP results

Blood pressure constantly fluctuates in most people. Taking multiple BP measurements each day, for multiple days in an environment where a person spends a significant amount of time, yields a more accurate and representative picture of that person's true BP. When compared with a single conventional office BP measurement, SMBP measurements taken over a week are much more predictive of future cardiovascular risk. Training patients to properly prepare for and perform SMBP is essential to obtain accurate measurements.

Ensuring use of validated blood pressure measurement devices

Blood pressure measurement devices used by patients for out-of-office measurements should be validated for clinical accuracy. Validated devices have passed an international validation protocol performed by independent skilled BP measurement experts. A preliminary list of BP measurement devices sold in the United States that meet criteria for the US Blood Pressure Validated Device Listing™ was made available on April 29, 2020. Additional validated BP measurement devices sold in the U.S. may be found on international validated device listings that are maintained by Canadian, European and British and Irish organizations.

Patients should use automated BP measurement devices with upper arm cuffs of appropriate size (PDF). Many devices are sold with cuffs that will fit arm circumferences within the small adult to large adult range, but not all devices have extra-large cuff sizes available. Using an inappropriately sized cuff can lead to inaccurate BP measurements, as can using cuffs on different areas of the body (e.g., finger cuffs). A wrist cuff (PDF) should only be used if an upper arm cuff is not clinically appropriate or if an appropriately sized upper arm cuff is not available.1

Because it is recommended that patients take SMBP measurements for 7 days, devices with the capacity to store at least 7 days of measurements (28 or more readings) are preferred.1

Selecting an SMBP cuff size

Blood pressure (BP) measurement devices with upper arm cuffs provide the most accurate measurements.1 Wrist cuffs are not recommended for clinical use unless patients cannot use upper arm cuffs due to arm size or other medical reasons.1 Finger devices are also not recommended for clinical use because these are less accurate than upper arm BP measurement devices.1

Below are steps to determine the appropriate upper arm cuff size. If possible. it may be easier for patients to have another person assist with the process.

Ask patients to gather the following items:

—Tape measure

—BP measurement device, cuff and manual (if device is already purchased)

Locate mid-upper arm:

—Measure the length of the arm between the acromion process (bony protuberance on shoulder) and the olecranon process (bony protuberance at elbow)

—Divide the distance in half to locate the mid-upper arm

Determine arm circumference:

—Wrap a tape measure around the mid-upper arm to determine arm circumference (typically measured in centimeters)

Determine cuff size:

—Based on arm circumference, determine the cuff size that is appropriate. Use this information to help with device selection. Many BP measurement devices have circumference ranges printed directly on the cuffs. This information can also often be found in the device manual or on the device box.

Blood pressure cuff size table

Modified from Table 3 in: Muntner P, Shimbo D, Carey RM, Charleston JB, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73:e35–e66. doi: 10.1161/HYP.000000000000008.

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References

1 Muntner P. Shimbo D. Carey RM. et al. Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension. 2019;73(5):e35-e66. doi: 10.1161/HYP.0000000000000087.
     

Download the 7-step SMBP quick guide

Our 7-step SMBP quick guide is a reference for physicians and care teams to help train patients to perform SMBP monitoring.

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Disclaimer: These steps are for informational purposes only. These steps are not intended as a substitute for the medical advice of a physician; they offer no diagnoses or prescription. Furthermore, this information should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, nor exclusive of other methods of care reasonably directed to obtaining the same results. This protocol reflects the best available evidence at the time that it was prepared. The results of future studies may require revisions to the recommendations in this protocol to reflect new evidence, and it is the clinician's responsibility to be aware of such changes.
    

Interpret results

Interpreting SMBP measurements

For SMBP measurement interpretation, an average systolic BP and average diastolic BP of 135/85 mm Hg is considered equivalent to 140/90 mm Hg in the clinical setting. If the BP used to diagnose hypertension and as a treatment target in the clinical setting is 140/90 mm Hg, the corresponding SMBP diagnostic threshold and treatment target is 135/85 mm Hg.

In the 2017 American College of Cardiology/American Heart Association "Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults," 130/80 mm Hg is used as the diagnostic threshold for hypertension.1 When following the recommendations in this guideline, 130/80 mm Hg can be used for most patients as the treatment target for hypertension in clinical settings and for SMBP. The ultimate judgment regarding treatment targets and management plans must be made by physicians and patients based on individual patient factors.

The measurement ranges and interpretations presented in the tables are based on the 2003 "Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure" (JNC-7) diagnostic and treatment target thresholds.2 If the 2017 ACC/AHA Hypertension Clinical Practice Guideline is used, hypertension is defined as BP > 130/80 mm Hg for both office-based measurements and SMBP, and controlled BP for most adults is defined as < 130/80 mm Hg.

SMBP classifications

Patients without a diagnosis of hypertension

Classifications for patients without hypertension table

Patients with an existing diagnosis of hypertension

Classifications for patients with hypertension table

  

For both tables, if systolic and diastolic BPs are in different categories, defer to the higher category of BP.

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References

1 Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA guideline for the prevention, detection, evaluation and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71(19).

2 Chobanian AV, Bakris GL, Black HR, et al; the National High Blood Pressure Education Program Coordinating Committee. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42:1206–52.
   

Download the 7-step SMBP quick guide

Our 7-step SMBP quick guide is a reference for physicians and care teams to help train patients to perform SMBP monitoring.

Horizontal line_1300

Disclaimer: These steps are for informational purposes only. These steps are not intended as a substitute for the medical advice of a physician; they offer no diagnoses or prescription. Furthermore, this information should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, nor exclusive of other methods of care reasonably directed to obtaining the same results. This protocol reflects the best available evidence at the time that it was prepared. The results of future studies may require revisions to the recommendations in this protocol to reflect new evidence, and it is the clinician's responsibility to be aware of such changes.

Coding

SMBP codes and descriptions

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

SMBP codes and descriptions table

SMBP CPT® coding

Download information on CPT codes for SMBP and remote physiologic monitoring services.

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 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.

Remote physiologic monitoring codes and descriptions

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.

Remote physiologic monitoring codes table

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.
    —CMS waiver 3/1/20-the Public Health Emergency (PHE): Consent may be collected at time of service. Cost sharing may be reduced or waived by physician/practitioner, sanctions are suspended.

—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.
    —CMS waiver (3/1/20–PHE): RPM services may be furnished to new patients in addition to established patients during the COVID-19 public health emergency.

—Monitoring must occur for at least 16 days within a month.
    —CMS waiver (3/1/20–PHE): Monitoring can last for fewer than 16 days, but no less than two days, for purposes of treating suspected or confirmed COVID-19.

—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.
    —CMS waiver (3/1/20–PHE): RPM services may be furnished to new patients in addition to established patients during the COVID-19 public health emergency.

—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.

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*Note

Current exceptions to codes as a result of COVID-19 may be in place by CMS and other payers. Patients may not be required to give consent to be enrolled in RPM and co-pays may be waived. In addition, RPM may be utilized for new and established patients without requiring a face-to-face E/M visit. 

Waivers and exceptions described in this document are temporary and effective March 1, 2020 through the end of the public health emergency (PHE), unless additional guidance is provided by CMS in the future.

Current CMS waivers (PDF)

Current CMS telehealth codes

RPM and chronic care management (CCM)

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.
   

Download the 7-step SMBP quick guide

Our 7-step SMBP quick guide is a reference for physicians and care teams to help train patients to perform SMBP monitoring.

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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. 

CPT © Copyright 2019 American Medical Association. All rights reserved. AMA and CPT are registered trademarks of the American Medical Association.