Kentucky Women’s Cancer Screening Program

1. Kentucky Women’s Cancer Screening Program Local Health Department Individual Provider Contract Training April 23, 2014

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 • TECHNICAL COMPONENT • PROFESSIONAL COMPONENT • GLOBAL/TOTAL OUTPATIENT RATE

7. Lab/Pathology 87621 88173 88141 88174 88142 88175 88143 88305 88164 88307 88165 88331 88172 88332 *88104

8. Breast Surgeon 10021 19082 19101 19283 10022 19083 19120 19284 19000 19084 19125 19285 19001 19085 19126 19286 19081 19086 19281 19287 19100 19282 19288 *19030 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 76098 77055 76645 77056 76942 77057 77053 77058 G0202 77059 G0204 G0206 *76937, *77052, *77054

11. Anesthesiologist 00400 *00940

12. 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.

13. Procedures that can be paid with state preventive block grant funds or other sources but cannot be reimbursed with KWCSP federal funds. 00940 99214 19030 99215 76937 W0166 77052 W9214 77054 W9215 88104

14. Deleted and New CPT Codes

15. 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, 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