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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
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.
Melody Stafford, Program Director Sivaram Maratha, Data [email protected] [email protected] x 4159 502-564-3236 x 4161
Carolyn Kerr, Clinical Coordinator [email protected] x 4160
Deborah Donovan, Quality Assurance Consultant, Eastern [email protected]
502-564-3236 x 4157
Regina Reid, Quality Assurance Consultant, Western KentuckyRegina [email protected]
270-404-1215
CONTACT INFORMATION