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    Health Service Code 67.89A

    Instillation or injection of contrast media for nephrostogram

    NOTE:
    1. May be claimed by the surgeon who performed the surgery only when the service is provided after the 14 day post-operative period.
    2. Benefit for injection of opaque media without intubation being required is included in X77A and X77B.
    Category:M+ Designated Minor Procedure
    Base rate:$32.37

    Fee modifiers:

    TypeCode# of callsExplicitActionAmount
    BMIBMIANTYesIncrease By25%
    ROLEANESTYesReplace Base$18.39
    ANEUANEU1For Each Call Pay Base At100%
    ANEUANEU2 - 2For Each Call Pay Base At75%
    ANUANU1For Each Call Pay Base At100%
    ANUANU2 - 150For Each Call Increase By$18.39
    CALLNBRSER1For Each Call Pay Base At100%
    CALLNBRSER2 - 2For Each Call Increase By$21.67
    SURCEVYesIncrease By$48.70
    SURCNTAMYesIncrease By$116.83
    SURCNTPMYesIncrease By$116.83
    SURCWKYesIncrease By$48.70
    LVPLVP75YesReduce Base To75%

    Governing Rules: