G288

PDF page 118 / GP104

GENERAL PREAMBLE
OTHER PREMIUMS
    Non-elective Surgical Procedures (including fractures or dislocations), Obstetrical Deliveries,
    Clinical Procedures Associated with Diagnostic Radiological Examinations, Ground Ambulance
    Transfer (K101), Air Ambulance Transfer (K111), Transport of Donor Organs (K102), Return
    Trip (K112), or one of the following Major Invasive Procedures:
    G060, G061, G062, G065, G066, G067, G068, G082, G083, G085, G090, G099, G117, G118,
    G119, G125, G176, G177, G178, G179, G211, G224, G246, G248, G249, G260, G261, G262,
    G263, G268, G269, G275, G277, G279, G280, G282, G287, G288, G290, G297, G298, G303,
    G309, G322, G323, G324, G330, G331, G336, G347, G348, G349, G356, G376, G379, G380,
    G509, J001 to J068, and X112 when required for intussusception

PDF page 386 / E2

CLINICAL PROCEDURES ASSOCIATED WITH DIAGNOSTIC
              RADIOLOGICAL EXAMINATIONS
ANGIOGRAPHY
                                                                                                                Spec          Anae
        Note:
        For cardiac catheterization procedures, see the Diagnostic and Therapeutic Procedures
        section of the Schedule.
    By catheterization - abdominal, thoracic, cervical or cranial
# J021 - insertion of catheter (including cut down, if necessary) and
          injection, if given................................................................. 186.05 6
# J022 - selective catheterization - add to catheter insertion fee (per
          vessel, to maximum of 4) ............................................each             92.15
      Payment rules:
      J021 and J022 are not eligible for payment in addition to cardiac catheterization procedures
      (Z439 to G288).
# J014       - selective catheterization for spinal and parathyroid
               angiography (“Selective” means manipulation of the
               catheter from the vessel of introduction into a branch
               tributary, or cardiac chamber with angiogram(s)) - add to
               catheter insertion fee .........................................................                  58.30
# J056       - transcatheter fibrinolytic therapy ........................................                     1027.95          7

PDF page 421 / J7

Vascular cannulation
  Z459 Arterial puncture ...................................................................... 10.20
# G268 Cannulation of artery for pressure measurements including cut
          down as necessary..............................................................       31.25
      Note:
      G268 is not eligible for payment with G249, G259, G261, G176, G177, G178, G288,
      Z443 or Z440.
# G269 Cannulation of central vein for pressure measurements or for
         feeding line - not to be billed with right heart catheterization
         (Z439) or with Swan-Ganz catheter insertion......................                           31.25
# G270 Intraosseous infusion...............................................................          23.90
# G309 Umbilical artery catheterization (including obtaining of blood
          sample)................................................................................    45.55
    Venipuncture
+ G480 - infant....................................................................................  9.90
+ G482 - child ..................................................................................... 7.35
+ G489 - adolescent or adult ..............................................................          3.54
     Note:
     G489 is not insured when rendered for the monitoring of adverse effects resulting from a calorie
     restricted weight loss program.
+ G483 Therapeutic venisection...........................................................             9.70
  G282 Umbilical vein catheterization (including obtaining of blood
          sample)................................................................................    43.60
# Z438 Insertion of Swan-Ganz catheter (not included in respiratory or
          critical care benefits) ...........................................................       162.50    6
          Note:
          1.Swan-Ganz catheter insertion is included in the anaesthesia basic units of any surgical
            services where anaesthesia basic units are listed
          2.Z438 includes dye dilution densitometry and/or thermal dilution studies, when rendered
            (except in the setting of a cardiac catheterization laboratory).
          [Commentary:
          See G285 for dye dilution densitometry and G286 for thermal dilution studies performed using a
          Swan-Ganz catheter in a cardiac catheterization laboratory.]
# Z456 Insertion of implantable central venous catheter .....................                       296.50    6
# Z457 Surgical removal or repair of tunneled central venous catheter                                60.00    6
# Z446 Insertion of subcutaneous venous access reservoir ...............                            168.00    6
# Z447 - revision same site................................................................         130.70    6
# E684           - when performed in infant or child, to Z456 or Z446 ....add                       233.65

PDF page 423 / J9

BLOOD TRANSFUSIONS
# G275 Exchange transfusion .............................................................         205.45
     Note:
     Assistant at exchange transfusion (see General Preamble GP85).
# G280 Intra-uterine fetal transfusion - initial or subsequent...............                     186.90
  G276 Donor cell pheresis (platelets or leukocytes) ..........................                    15.35
    Therapeutic plasma exchange
# G277 - initial and repeat, to a maximum of 5 per year ............each                           82.00
# G278 - more than 5 per year ..................................................each               41.80
# G272 Manual plasmapheresis (see General Preamble GP12) ........                                 I.C
    LDL apheresis
# G287 - initial and repeat, to a maximum of 5 per year ...........each              82.00
# G290 - more than 5 per year ..................................................each 41.80
     Note:
     LDL apheresis is an insured service only for the treatment of homozygous familial
     hypercholesterolemia.
    CARDIOVERSION
# Z437 Cardioversion (electrical and/or chemical) - maximum of three
         sessions per patient, per day .............................................               92.45    6
        CARDIAC CATHETERIZATION
          Note:
          1.Cardiac catheterization procedures (Z439 to G288) include insertion of catheter (including
            cutdown and repair of vessels if rendered), catheter placement, contrast injection, imaging
            and interpretation.
          2.When more than one procedure is carried out at one sitting, the additional procedures are
            payable at 50% of the listed benefits. (Z439 to G288, excluding G262 and G263).

PDF page 427 / J13

Electrophysiologic pacing, mapping and ablation
# G178 - catheter ablation therapy....................................................            352.05
# G179 - repeat pacing, mapping and catheter ablation for additional
          distinct arrhythmia(s) without the use of an advanced
          mapping system .................................................................        111.20
          Note:
          G179 is not eligible for payment with Z423.
# Z424         - transseptal left heart catheterization, with or without
                 pressure measurements, with or without dye injection.......                      297.15    6
          Note:
          1.Z424 is only eligible for payment when rendered with G176, G177 and/or G178.
          2.Z424 is eligible for payment for each transseptal catheter placement to a maximum of 2.
# Z422         - retrograde aortic left heart catheterization with or without
                 pressure measurement(s) ..................................................       210.55    6
          Note:
          1.Z422 is only eligible for payment when rendered with G176, G177 and/or G178.
          2.Z422 is limited to a maximum of one per electrophysiological pacing, mapping and/or
            ablation sitting.
   G115 External cardiac pacing (temporary transthoracic) once per 24-
          hour period .........................................................................    46.30
      Note:
      G115 is not eligible for payment with G521, G522, G523, G395 and G391.
# G366 Testing of arrhythmia inducibility by acute administration of
         anti-arrhythmic or adrenergic drugs to a maximum of 2 per
         24 hours .............................................................................   148.50
          Note:
          G366 is not eligible for payment for the use of isoproterenol for arrhythmia induction when
          rendered with G261 and/or G259.
# Z443 Insertion of temporary endocardial electrode .........................                     154.10    6
# Z431 Repositioning of temporary endocardial electrode .................                          64.25    6
    Endomyocardial Biopsy
# G288 - transvascular, right or left ...................................................         200.00
    Tilt table testing of vasomotor syncope
# G314 - to include arterial cannulation, provocative and blocking
           drugs, physician must be continually present.....................                      112.00

Master, record 2001. Record Layout PDF, page 1.

G28820250401999999990000200000000001000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.