Kentucky Women’s Cancer Screening Program

Local Health Department Individual Provider Contract

TrainingApril 23, 2014

FY 2012/KWCSP RATE SHEET

Contracted Provider Name_______________ Local Health Dept. Name_________________________

KENTUCKY WOMEN’S CANCER SCREENING PROGRAM

NEGOTIATED RATES SHEET

The list below includes the CPT code and negotiated rates for this specific KWCSP provider contract with the Local Health Department. Enter the technical and professional rates for CPT codes only when 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.

The link below will take you to the current version of the Core Clinical Service Guide.

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 health

department.

http://chfs.ky.gov/dph/CCSG.htm

CPT CODE TECHNICAL COMPONENT

PROFESSIONAL COMPONENT

GLOBAL/TOTAL OUTPATIENT RATE

IF APPLICABLE, THE TOTAL NUMBER OF MAMMOGRAMS PERFORMED UNDER THE TERMS OF THIS CONTRACT SHALL NOT EXCEED _______ UNLESS AUTHORIZED BY THE HEALTH DEPARTMENT IN WRITING.

Contracted Provider Name_______________________Local Health Depart. Name______________________KENTUCKY WOMEN’S CANCER SCREENING PROGRAMNEGOTIATED RATE SHEETThe 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.

Contract Rate Sheet

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

Contract Rate Sheet (Cont.)

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.

Changes/Additions in Body of Contract

CPT CODETECHNICAL COMPONENT

PROFESSIONAL COMPONENTGLOBAL/TOTAL OUTPATIENT RATE

Table Column Headings

87621 88173

88141 88174 8814288175

88143 88305

88164 88307

88165 88331

88172 88332 *88104

Lab/Pathology

10021 19082 19101 19283

10022 19083 19120 19284

19000 19084 19125 19285

19001 19085 19126 19286

19081 19086 19281 19287

19100 19282 19288

*19030Also evaluation/management and preventative codes

99201-99396

Breast Surgeon

57452 57460 57520

57454 57461 57522

57455 57500 58100

57456 57505 58110

Also evaluation/management and preventative codes 99201-99396

Gynecologist

76098 77055

76645 77056

76942 77057

77053 77058

G0202 77059

G0204 G0206

*76937, *77052, *77054

Radiologist

00400

*00940

Anesthesiologist

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.

Billing for Procedures Performed in Hospitals

00940 99214

19030 99215

76937 W0166

77052 W9214

77054 W9215

88104

Procedures that can be paid with state preventive block grant funds or other sources but cannot be

reimbursed with KWCSP federal funds.

Deleted and New CPT Codes

Melody Stafford, Program Director Sivaram Maratha, Data ManagerMelody.Stafford@ky.gov SivaramR.Maratha@ky.gov502-564-3236 x 4159 502-564-3236 x 4161

Carolyn Kerr, Clinical Coordinator Carolyn.Kerr@ky.gov502-564-3236 x 4160

Deborah Donovan, Quality Assurance Consultant, Eastern KentuckyDeborah.Donovan@ky.gov

502-564-3236 x 4157

Regina Reid, Quality Assurance Consultant, Western KentuckyRegina .Reid@ky.gov

270-404-1215

CONTACT INFORMATION