Kentucky Women’s Cancer Screening Program

1. Kentucky Women’s Cancer Screening Program Local Health Department Individual Provider Contract Training April 10, 2013

3. Contract Rate Sheet • Contracted Provider Name_______________________ • Local Health Depart. Name______________________ • KENTUCKY WOMEN’S CANCER SCREENING PROGRAM • NEGOTIATED RATE SHEET • The list below includes the CPT code and negotiated rates for this specific KWCSP provider contract with the Local Health Department (LHD). Enter the technical and professional rates for CPT codes where it is applicable. • This list should only include the CPT codes that will be reimbursed to this contracted provider by the LHD. Use multiple copies of this form for additional codes.

4. Contract Rate Sheet (Cont.) • The link below will take you to the current version of the Core Clinical Service Guide (CCSG). The Cancer Screening/Follow-Up Section, found in the CCSG, is to be utilized by the provider when providing services to cancer screening patients referred by the LHD. http://chfs.ky.gov/dph/CCSG.htm

5. Changes/Additions in Body of Contract • If a LHD adds additional language or information to the body of a contract outside of the template form, the LHD will be responsible for those additions and/or changes. • Changes may be made that require additional services from a provider but they must at least cover the minimum requirements listed in the CCSG Cancer Screening Follow-Up Section.

6. Table Column Headings • CPT CODE • GLOBAL RATE • TECHNICAL ONLY • PROFESSIONAL ONLY

7. Lab/Pathology 87621 88173 88104 88174 88141 88175 88142 88305 88143 88307 88164 88331 88172 88332

8. Breast Surgeon 10021 19100 19125 10022 19101 19126 19000 19102 19290 19001 19103 19291 19030 19120 19295 S0613 Also evaluation/management and preventative codes 99201-99396

9. Gynecologist 57452 57460 57520 57454 57461 57522 57455 57500 58100 57456 57505 58110 Also evaluation/management and preventative codes 99201-99396

10. Radiologist 10021 19102 76645 77054 10022 19103 76937 77055 19000 19290 76942 77056 19001 19291 77031 77057 19030 19295 77032 G0202 19100 76098 77052 G0204 77053 G0206

11. Anesthesiologist 00400 00940

12. Hospital W0166 77057 77052 G0202 77053 G0204 77054 G0206 77055

13. Services Performed in Hospital CPT Codes: • (00400,00940) anesthesia • (10021-19295) breast surgeries • (57452-58100) cervical surgeries

14. Billing for Procedures Performed in Hospitals • If the hospital employs the surgeons and anesthesiologists and pay them salaries, the hospital may bill for the services that these providers perform. The individual providers may not be allowed to bill separately. • When lab specimens are evaluated at the hospital lab instead of being sent out, the hospital may bill for these services. • Only one provider may bill for each service and you will need to determine whether it should be the hospital or the physician by discussing their arrangements at contract negotiation time.

15. Kentucky Women's Cancer Screening Program Approved CPT Codes and Reimbursement Rates for Breast and Cervical Cancer Screening and Follow-up (Services may be provided either on site or off site as appropriate)

19. CONTACT INFORMATION Melody Stafford, Program Director Sivaram Maratha, Data Manager Melody.Stafford@ky.gov SivaramR.Maratha@ky.gov 502-564-3236 x 4159 502-564-3236 x 4161 Carolyn Kerr, Quality Assurance Consultant and Clinical Coordinator Carolyn.Kerr@ky.gov 502-564-3236 x 4160 Deborah Donovan, Quality Assurance Consultant, Eastern Kentucky Deborah.Donovan@ky.gov 502-564-3236 x 4157 Regina Reid, Quality Assurance Consultant, Western Kentucky Regina .Reid@ky.gov 270-404-1215