G921

PDF page 492 / J78

Payment rules:
        1. G920 and G234 are each limited to a maximum of one unilateral or one bilateral procedure
          per patient per day to a limit of 24 services for any combination of unilateral and bilateral
          procedures per patient per 12 month period. G236 is limited to a maximum of one per patient
          per day to a limit of 12 per patient per 12 month period. If, in the opinion of the treating
          physician, more frequent treatments 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.
        2. G920, G234 and G236 are only eligible for payment same patient same day with other nerve
          block and/or injection services if rendered to diagnose or treat a separate condition.
        3. G234 is not eligible for payment with G920 same patient same day.
        4. The sympathetic block that may result from epidural, spinal, plexus and peripheral nerve
          blocks is not payable as G920, G234 or G236.
    Miscellaneous
# G374 I.V. regional guanethidine .......................................................                        54.30
    Ganglion/Plexus injections
  G233 Percutaneous celiac, splanchnic or hypogastric ganglion/
         plexus block with fluoroscopic guidance ............................                                  200.00
  E444   - with radiofrequency ablation, to G233 .............. add 50%
  G217 Percutaneous trigeminal ganglion block with fluoroscopic
         guidance.............................................................................                 200.00
  G232 Percutaneous spheno-palatine ganglion block with
         fluoroscopic guidance.........................................................                        150.00
  E445   - when alcohol or other sclerosing solutions are used, to
           G920, G234, G236, G233, G217 or G232 ......... add 50%
  G921 Spheno-palatine ganglion block, transnasal topical, uni or
        bilateral...............................................................................                 12.50
     Payment rules:
     G921 is not eligble for payment same patient same day with G232.

Master, record 2423. Record Layout PDF, page 1.

G92120250401999999990000012500000000000000000000000000000000000000000000000

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.