MyCare Hypertension

NV is a 41 yo woman with obesity (BMI 32) and headaches. She recently became your patient when her insurance changed. She recalls being told she had high BP by her prior doctor but never started treatment. She acknowledges being anxious at the doctor’s office.

• Office BP visit 1: 152/92

• Office visit 2: 135/94, EKG normal SR, no LVH; normal Cr; Arm circumference = 16”

You recommend she obtain an Omron-3 home BP device (comes with a cuff that fits arm circumference of 9” to 17”) and refer her to MyCare Hypertension. You ask her to bring her home BP device to her next office visit.

Home BP readings in 1st month:

Average home BP 129/79, 20 readings

You call her after 1 month to tell her she has elevated BP, but not hypertension (as per AHA/ACC guidelines)

You agree together that she will work on increasing walking, decreasing portion size, and speaking with the nutritionist about the DASH diet

You recommend she continue monitoring her BP at home intermittently as she is at increased risk for transitioning to stage 1 hypertension by virtue of having white-coat hypertension.

As your patient met the threshold of 12 BP readings in a month, you bill for SMBP using CPT 99474 along with documenting your telephone call in Epic.

2 years later, she comes for an urgent care walk-in visit after being found to have severely elevated BP in dentist office: (BP 182/112), but no symptoms of headache or chest pain.

At walk-in visit, office BP still elevated 172/108. She does not have any recent home BP readings.

You re-refer her to MyCare Hypertension and ask her to start tracking her home BP readings again in MyChart.

This time, average home BP 144/95, 16 readings

You initiate amlodipine 5mg/HCTZ 12.5 mg

One month later, home BP 127/78, no titrations were necessary

Take Home Points:

1. MyCare Hypertension is useful for assessing white-coat hypertension (BP elevated in office, but non-elevated at home)

2. Patients with white-coat hypertension are at increased risk of converting to sustained hypertension and will benefit from periodic home BP monitoring

3. Lifestyle recommendations are still important for patients with elevated BP

4. Prescribe validated home BP devices, use ValidateBP.org to find validated devices or become familiar with a commonly available accurate device

5. Initiate combinations of 2 BP medications in patients with stage 2 hypertension. This leads to less need for multiple titrations to get patients to goal and higher patient satisfaction.

AZ is a 69 yo M, still works as superintendent of an apartment bldg, has mild OA

Medications: acetaminophen, amlodipine 10, HCTZ 25, lisinopril 40

Office BP 146/94

You refer to MyCare Hypertension to determine if he really needs more BP medications.

Home BP readings in first month:

Average home BP: 142/92, 18 readings

Normal Cr, l, K+4.2; aldo 10, renin 1.4

He misses his follow-up appointment, but you catch him on his cell phone.

He agrees to trialing eplerenone 25mg as a 4th line medication even though his labs were not consistent with primary hyperaldosteronism.

As your patient met the threshold of 12 home BP readings in a month, you bill for SMBP using CPT 99474 along with documenting your telephone call in Epic.

Average home BP 1 month later: 135/88, K+4.3

You call him, and he agrees to uptitrate eplerenone to 50mg

As your patient again met the threshold of 12 BP readings in a month, you bill for SMBP using CPT 99474 along with documenting your telephone call.

You see him in your office 6 weeks later

You review his home BP data and labs in advance of his visit

Office BP 135/88; home BP 128/76; normal renal panel

You congratulate your patient on getting his BP under control, explaining that the home BP average is the most important.

You continue MyCare Hypertension for 6 months total to ensure consistent BP control

Although the office visit only took 15 min (99212), you bill for 20 min of work to encompass the additional time you spent reviewing home BP data in advance of visit (99213)

Take Home Points

1. MyCare Hypertension is useful for motivating patients to track their BP at home, which can provide you with the BP readings you need to confirm patients have true resistant hypertension and benefit from adding a 4th medication

2. Time spent reviewing data for home BP monitoring can be incorporated into E&M upcoding if done on same day as the office visit

DJ is a 49 yo M with a family history of early MI and stroke, He has DM on metformin, and hypertension. He is overweight: BMI 29

He is prescribed lisinopril 40, HCTZ 25, amlodipine 10

Office BP: 141/91; Normal renal panel, K+ 4.8

As he already has his own BP device, you refer patient to MyCare Hypertension

Average home BP 1 month later: 140/92, 18 readings

You call patient to discuss treatment options, including adding carvedilol which would be a twice a day medication. You had consider spironolactone but were concerned by the borderline high K+.

He declines to increase his BP medications. He wishes to test better lifestyle management based on what he is learning through the MyCare Hypertension modules. This includes reducing salt in his diet, controlling his stress with meditation, and using a pillbox to help avoid forgetting his medications.

Average home BP at Month 2: 134/82, 16 readings.

Your nurse calls patient on your behalf to discuss results and treatment options. Patient again declines to initiate more BP medication. He prefers to continue to work on lifestyle changes.

As your patient met the threshold of 12 BP readings in a month, you bill for SMBP using CPT 99474 along with documenting the nurses telephone call.

You see patient in the office again at Month 3

Office BP 134/84, average home BP in Month 3: 129/79, 18 readings.

BMI now 27

You congratulate your patient on achieving controlled BP and weight loss.

You recommend ongoing home BP monitoring with patients self-entering BP readings through 6 months.

Take home points:

MyCare Hypertension can improve BP control through increasing patient adherence to medications and lifestyle

Many patients like monitoring their BP at home to test out their ideas for lowering BP without medication

The time your staff (nurses, assistants) spends communicating your plan to patients engaged in home BP monitoring can be used to apply SMBP billing code 99474 on a monthly basis so long as patients have 12 readings in prior month.

At least some synchronous communication (e.g., telephone or video call) with patients is required to bill for SMBP. MyChart messages, alone, are not sufficient.

ZZ is a 72 yo M with long standing hypertension, stage 4 CKD, CAD, and IDDM.

His office BP is 162/88.

BP medications include: chlorthalidone 25, nifedipine ER 90, furosemide 20

Renal panel has Cr 2.8, K+ 4.8

You refer patient to MyCare Hypertension.

Average home BP 6 weeks later: 148/95, but home BP readings range from 104/66 to 180/112 and pulse ranges from 60-88.

Patient describes occasional dizziness, but not clearly related to when he has low BP readings.

Patient has good understanding of his BP medications and uses a pillbox.

You review his prescription fill data in Epic and see all his BP medications have recent fill dates

You add carvedilol 6.25 bid.

Average home BP 3 months later: 144/92, home BP readings range from 96/56 to 178/110 and pulse ranges from 48-88.

You order eConsult Hypertension Center for advice on titrating his BP regimen.

You refer patient to nephrology for assistance managing his CKD and uncontrolled, labile BP.

Take Home Points:

MyCare Hypertension can be used to identify challenging patients with true resistant hypertension and labile home BP readings

Epic can be used to determine whether patients are filling their BP medications.

Use a team approach to try to get these challenging, high-risk patients to goal.

E-consult for hypertension can be used for quick advice on challenging hypertension cases.

Consultants that may be helpful for co-managing complex hypertension include:

• pharmacists, especially helpful for medication reconciliation and adherence counseling

• cardiologists or nephrologists if underlying CKD

• Columbia Hypertension Center, includes cardiology and nephrology experts in hypertension management (Epic order, 212-342-1273 or https://www.columbiadoctors.org/specialties/cardiology-cardiac-surgery/our-services/hypertension-center)