What CPT codes are used for hypertension follow-up visits?

Use E/M codes 99212-99215 based on MDM complexity. Straightforward BP check with stable meds may support 99213; multiple medication adjustments or comorbidities support 99214. Add 93784-93790 for ambulatory BP monitoring if performed. Home BP monitoring interpretation is included in E/M; no separate code exists.

What blood pressure documentation is required for quality measures?

Document: BP reading with date, position (seated), cuff size, arm used, and home BP log review if available. Quality measures typically require BP <140/90 or <130/80 depending on measure. Document multiple readings if elevated (average of 2 readings preferred). Include BP at goal status and action taken if not at goal.

How should home blood pressure monitoring be documented?

Document: home BP device validated, patient educated on proper technique, review of home BP log (average readings, number of readings, time of day), comparison to office readings, and how home readings influence management. Home BP <135/85 corresponds to office <140/90. Include assessment of 'white coat' or 'masked' hypertension if suspected.

What documentation supports medical necessity for medication adjustment?

Document: current BP with comparison to goal, current regimen with doses and adherence, reason for change (not at goal, side effects, cost, simplification), evidence supporting new medication choice, and expected benefit. Reference guidelines (JNC8, ACC/AHA) when supporting treatment decisions. Include drug-disease interactions considered.

How do I document lifestyle modifications for hypertension?

Document: DASH diet counseling, sodium restriction (<2300 mg/day goal), physical activity recommendations (150 min/week moderate), weight management if overweight (document BMI and goal), alcohol moderation if applicable, and smoking cessation if applicable. Document patient's current status and barriers to lifestyle change. This supports comprehensive hypertension care.

Primary Care — Hypertension Follow-up Template

Primary Care Internal Medicine Updated: 11/7/2025

The Hypertension Follow-up Visit Template is designed for primary care providers, internists, and cardiologists managing patients with hypertension. This focused template documents blood pressure control, medication adherence, lifestyle factors, and treatment optimization. The template supports appropriate billing for chronic disease management visits and includes sections for blood pressure trends including home monitoring data, medication review with adherence assessment and side effects, lifestyle factors including diet, exercise, sodium intake, and alcohol consumption, physical examination including blood pressure measurement and cardiovascular assessment, assessment of hypertension control status, medication adjustments including dose changes or additions, patient education on hypertension management and lifestyle modifications, and follow-up planning. This template ensures comprehensive hypertension care, supports blood pressure control goals, facilitates medication optimization, and improves patient outcomes through systematic management. Ideal for primary care practices managing hypertension, cardiology practices, and practices participating in hypertension quality improvement programs.

Template

Interactive Mode

Audit Bill

Chief Complaint

Hypertension management.

HPI

BP logs/home readings, symptoms (HA, vision, chest pain), adherence, side effects, lifestyle.

Exam

Vitals with seated/standing BP, CV, lungs, edema, fundoscopic (as indicated).

Assessment & Plan

Stage/goal; adjust medications; labs (BMP); lifestyle counseling; follow-up interval.

💡 Tip: Click anywhere to edit. Changes are temporary.

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