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    Health Service Code 16.89D

    Percutaneous facet joint injection - Lumbar/Sacral

    NOTE:
    1. A maximum of four calls may be made per patient, per day regardless of level (HSCs 16.89B, 16.89C or 16.89D).
    2. A maximum of twelve calls may be claimed per patient, per benefit year regardless of level (HSCs 16.89B, 16.89C or 16.89D).
    3. HSCs 16.89B, 16.89C and 16.89D may not be claimed in addition to HSCs 13.53B, 13.59J, 92.78B or 92.78C.
    4. HSCs X 55 or X 56 may only be claimed in addition to HSCs 16.89B, 16.89C or 16.89D once per year, per patient.
    Additional notes:
    • Listed under 16 - OPERATIONS ON SPINAL CORD AND SPINAL CANAL STRUCTURES:

      The listed benefits are payable irrespective of the number of vertebrae involved if one incision utilized, unless otherwise stated.

    Category:M+ Designated Minor Procedure
    Base rate:$106.75

    Fee modifiers:

    TypeCode# of callsExplicitActionAmount
    CALLNBRSER1For Each Call Pay Base At100%
    CALLNBRSER2 - 4For Each Call Pay Base At75%
    TRAYMINTIncrease By$13.11
    NBTRNBTRYes
    SURCEVYesIncrease By$48.70
    SURCNTAMYesIncrease By$116.83
    SURCNTPMYesIncrease By$116.83
    SURCWKYesIncrease By$48.70
    LVPLVP75YesReduce Base To75%

    Governing Rules:

    • 6.6.2

      If a procedure designated "+" is performed in a physician's office, both the procedural benefit and the appropriate office visit benefit for that day may be claimed, but if a consultation benefit pursuant to GR 6.6.4 has been claimed, a visit benefit will not be payable for the day on which the procedure is performed.

    • 6.6.3

      If a procedure designated "+" is performed in a place other than a physician's office, either a procedural benefit or a visit benefit, but not both, may be claimed for that day.

    • 6.6.4

      If a procedure designated "+" and a consultation are provided on the same day, both the procedural benefit and the appropriate consultation benefit are payable.

    • 6.7.1

      If a minor procedure (M or M+) is provided with a hospital visit on the same day, only the greater benefit HSC may be claimed.

    • 14.2 MINOR TRAY SERVICE

      A minor tray service benefit may be claimed for the following procedures only when they are performed in a location other than a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with a regional health authority to provide any of these insured services.

    • 14.3 MULTIPLE TRAY SERVICE

      If multiple procedures listed under GRs 14.1 and 14.2 are performed during the same encounter in a location other than a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with a regional health authority to provide any of these insured services, the following applies:

    • 14.3.1

      For the same anatomical area (example - 3 moles removed from the face), only one tray may be claimed except when the condition relates to suspected cancer or infection, in which case, if required, additional tray(s) may be claimed at 50%.

    • 14.3.2

      For different anatomical areas, the tray for the initial procedure may be claimed at 100% and if required, the tray for each additional procedure may be claimed at 50%.

    • 14.3.3

      Benefits for additional trays may not exceed the benefit listed for one major tray.