G915

PDF page 489 / J75

Payment rules:
          1. G914 is only eligible for payment when a fluoroscopically guided facet injection has been
            rendered for the same site(s) within the previous 12 month period by the same physician.
          2. G913 and G915 are each limited to a maximum of 7 services per patient per day.
          3. G910, G911, G912 or G914 are each limited to 6 services per patient per 12 month period.
            If, in the opinion of the treating physician, more frequent services are necessary, the
            physician may obtain written prior authorization from the MOH. Authorization will be
            dependent on the physician demonstrating that the increased frequency of the service is
            generally accepted as necessary for the patient under the circumstances.
     Sacroiliac joint injections
   G916 Percutaneous diagnostic and/or corticosteroid sacroiliac joint
          injection with fluoroscopic guidance, unilateral ..................                   75.00
     Nerve root injections
   G917 Percutaneous diagnostic selective nerve root block with
          fluoroscopic guidance, with or without contrast – any
          number of sites...................................................................   160.00
          Payment rules:
          G917 is limited to a maximum of 1 service per patient per week and a maximum of 12 services
          per patient per 12 month period.

Master, record 2417. Record Layout PDF, page 1.

G91520250401999999990000014000000000000000000000000000000000000000000000000

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.