LCD : Adenosine (Adenocard) (L13243)

LCD for Adenosine (Adenocard) (L13243)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L13243

LCD Title

Adenosine (Adenocard)

Contractor's Determination Number

L13243

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, section 1861(s). These sections outline coverage for drugs and biologicals and services and supplies.

CMS Pub 100-4, 13 §§10.2, 20.2.1

CMS Pub 100-4, Transmittal 514, CR 3756

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
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California
Colorado
Connecticut
Florida
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Hawaii
Iowa
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South Carolina
Tennessee
Texas
Utah
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Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 09/30/2003

Original Determination Ending Date

Revision Effective Date

For services performed on or after 12/17/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Indications Summary

Adenosine is an endogenous nucleoside occurring in all cells of the body. Adenosine helps protect the heart muscle from damage when myocardial ischemia occurs. It can slow conduction time through the A-V node, can interrupt the reentry pathways through the AV-node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT), including PSVT associated with Wolff-Parkinson-White Syndrome.

Adenosine is an antiarrhythmic drug that is not chemically related to other antiarrhythmic drugs. It is a sterile solution for rapid bolus intravenous injection that should be administered either directly into a vein or, if given into an IV line, it should be given as close to the patient as possible and followed by a rapid saline flush. Adenosine is removed from the circulation very rapidly with a half-life estimated to be less than 10 seconds.

Adenosine is also used as a diagnostic aid in noninvasive testing in conjunction with myocardial perfusion scans for patients with suspected or known coronary artery disease.

Indications:

Intravenous adenosine is indicated for:

Conversion to sinus rhythm of paroxysmal supraventricular tachycardia (PSVT), including that associated with accessory bypass tracts (Wolff-Parkinson-White Syndrome).

The recommended intravenous dose for adults is an initial dose of 6 mg given as a rapid intravenous bolus (administered over a 1-2 second period). If the first dose does not result in elimination of the supraventricular tachycardia within 1-2 minutes, 12 mg should be given as a rapid intravenous bolus. This 12 mg dose may be repeated a second time if required. Doses greater than 12 mg are not recommended.

When clinically advisable, appropriate vagal maneuvers (e.g., Valsalva maneuver), should be attempted prior to adenosine administration.
As an adjunct to noninvasive testing in conjunction with myocardial perfusion scans to produce pharmacologic stress in those patients who are unable to exercise adequately (i.e., the inability to obtain 75-100% of their age-predicted heart rate through exercise). Examples of patients who may be unable to exercise include, but are not limited to the following: patients with musculoskeletal abnormalities, severe peripheral vascular disease, patients receiving medications such as beta blockers and calcium channel blockers that decrease heart rate, etc.

The infusion rate for Adenosine is based on the patients weight and is typically administered at 140 mcg/kg/min over 6 minutes (total dose of 0.84 mg/kg).
To briefly cause AV block to identify atrial fibrillation or atrial flutter waves when the patient presents with rapid atrial tachycardia.

Normally, an initial dose of 6 mg rapid IV bolus is given with the dose doubled within 2 minutes if no response.
As a trial dose in stable patients with wide-complex tachycardia based on Advanced Cardiac Life Support (ACLS) protocol.

Normally the trial dose includes a bolus of 6 mg, followed either with another 6 mg dose or 12 mg dose.
As a diagnostic and/or therapeutic agent for patients undergoing electrophysiology studies. The administration of Adenosine is given as a bolus.
Measurement of fractional flow reserve (FFR) during cardiac catheterization to assess ischemic potential of a moderately stenosed (50-80%) coronary artery. A FFR index of 0.75 or less is considered a functionally ischemic lesion.

The administration of adenosine is either given intravenously and/or intracoronary. It is expected that the FFR obtained is used in the clinical decision making of future treatments (e.g., revascularization).

Limitations:

Adenosine is contraindicated in patients with:

Second- or third-degree AV block (except in patients with a functioning artificial pacemaker);
Sick sinus syndrome (except in patients with a functioning artificial pacemaker);
Atrial flutter, atrial fibrillation, and ventricular tachycardia (except as indicated above);
Suspected bronchoconstrictive or bronchospastic lung disease (e.g. asthma);
Known hypersensitivity to adenosine

Coverage Topic

Prescription Drugs

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0636	Drugs requiring specific identification-detailed coding (eff 3/92)

CPT/HCPCS Codes

Effective for services furnished on or after April 1, 2005, hospitals should use HCPCS C9223, Injection, adenosine for therapeutic or diagnostic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) instead of HCPCS codes J0150, Injection, adenosine, for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) and J0152, Injection, adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds, instead use A9270 Effective April 2005, J0150 and J0152 will be assigned to status indicator “B”.
C9223 will be discontinued after 01/01/2006

J0150	INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270)
J0152	INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; INSTEAD USE A9270)

ICD-9 Codes that Support Medical Necessity

396.0 - 396.9	MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MITRAL AND AORTIC VALVE DISEASES UNSPECIFIED
411.0	POSTMYOCARDIAL INFARCTION SYNDROME
411.1	INTERMEDIATE CORONARY SYNDROME
411.81	ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION
411.89	OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER
412	OLD MYOCARDIAL INFARCTION
413.0 - 413.9	ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS
414.00 - 414.06	CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART
414.10 - 414.19	ANEURYSM OF HEART (WALL) - OTHER ANEURYSM OF HEART
414.8	OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE
414.9	CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED
424.0	MITRAL VALVE DISORDERS
426.2	LEFT BUNDLE BRANCH HEMIBLOCK
426.3	OTHER LEFT BUNDLE BRANCH BLOCK
426.4	RIGHT BUNDLE BRANCH BLOCK
426.50 - 426.54	BUNDLE BRANCH BLOCK UNSPECIFIED - TRIFASCICULAR BLOCK
426.6	OTHER HEART BLOCK
426.7	ANOMALOUS ATRIOVENTRICULAR EXCITATION
426.81	LOWN-GANONG-LEVINE SYNDROME
427.0	PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
427.2	PAROXYSMAL TACHYCARDIA UNSPECIFIED
427.31	ATRIAL FIBRILLATION
427.32	ATRIAL FLUTTER
428.0 - 428.9	CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
440.21 - 440.24	ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION - ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE
785.0	TACHYCARDIA UNSPECIFIED
794.31	NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)
960.7	POISONING BY ANTINEOPLASTIC ANTIBIOTICS
E942.0	CARDIAC RHYTHM REGULATORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
E942.1	CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
V67.00	FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY
V67.09	FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY
V67.51	FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED
V67.59	OTHER FOLLOW-UP EXAMINATION
V81.0	SCREENING FOR ISCHEMIC HEART DISEASE

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

Medical record documentation must support the medical necessity for the use of Adenosine. If the Adenosine is used as a pharmacologic stress agent, then the documentation must support the medical condition that prohibits the patient from exercising adequately. For all indications, the documentation must indicate the strength and amount of Adenosine administered to the patient.

If documentation is requested for review, submit the following:

History and Physical
Physician orders/progress notes
Nurses notes
Medication sheet indicating the name of drug, the dosage and route administered
Diagnosis(es)/reason for drug
Test results
Itemization of charges

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

Other Contactors Policy (First Coast Service Options, Inc.)

Mosby’s Drug Consult. Copyright 2002.

Atkins, Dianne MD. Dorian, Paul MD. “Treatment of Tachyarrhythmias”. Annals of Emergency Medicine. Vol. 37; No.4; April 2001.

Davis, Robert MD. Spitalnic, Stuart MD. Jagminas, Liudvikas MD. “Cost-effective Adenosine Dosing for the Treatment of PSVT”. American Journal of Emergency Medicine. Vol.7; No. 7; Nov 1999.

Jeremias, Allen MD. Whitbourn, Robert MBBS. “Adequacy of Intracoronary versus Intravenous Adenosine-induce maximal coronary hyperemia for Fraction Flow Reserve measurements”. American Heart Journal. Vol. 140; No. 4; October 2000.

Heidland, Ulrich MD. Heintzen, Matthias MD. “Preconditioning during Percutaneous Transluminal Coronary Angioplasty by Exogenous and Endogenous Adenosine.” American Heart Journal. Vol.140; No.5; Nov.2000.

Voci, Paolo MD. Pizzuto, Francesco MD. “Measurement of Coronary Flow Reserve in the Anterior and Posterior Coronary Arteries by Transthoracic Doppler Ultrasound”. The American Journal of Cardiology. Vol.90; No. 9; Nov.2002.

Advisory Committee Meeting Notes

Public Open Meeting to discuss the draft policy was held 06/05/2003.

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

05/02/2003

End Date of Comment Period

06/15/2003

Start Date of Notice Period

08/14/2003

Revision History Number

L13243a

Revision History Explanation

08/11/2004 Crosswalked references to Online Manual

11/07/2004 - The description for CPT/HCPCS code J0150 was changed in group 1

01/29/2005 - CPT/HCPCS code J0151 was deleted from group 1

02/14/2005 - CPT/HCPCS code J0152 was added to group 1

06/02/2005 - CPT/HCPCS code C9223 was added to group 1, text was added to paragraph 1, group 1: Effective for services furnished on or after April 1, 2005, hospitals should use HCPCS C9223, Injection, adenosine for therapeutic or diagnostic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) instead of HCPCS codes J0150, Injection, adenosine, for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) and J0152, Injection, adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds, instead use A9270 Effective April 2005, J0150 and J0152 will be assigned to status indicator “B”. Text in LMRP Description-billing guidelines revised to read: For most revenue codes, Hospital Outpatient Prospective Payment System (OPPS) requirements mandate HCPCS coding on the claim. When the revenue code you are reporting requires HCPCS coding, choose the appropriate code(s) from the list below when submitting your claim to Medicare. (Note: Effective for services furnished on or after April 1, 2005, HCPCS code J0152 is for use by non-OPPS providers only. OPPS providers are to use C9223.)
Non-OPPS Providers must bill using J0150 for single and multiple 6mg/12 mg injections for therapeutic use and bill using J0152 for diagnostic use. Adenocard (J0150) 6 mg is equal to one billing unit; 30 mg of adenosine equals one billing unit for J0152".

11/26/2005 - CPT/HCPCS code C9223 was deleted from group 1

This LCD was converted from an LMRP on 12/16/2005

7/2/2006 - The description for Bill code 14 was changed

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

10/02/2007 - Frequently Asked Questions restored to Appendices.