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

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. 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. 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 CODE TECHNICAL COMPONENT PROFESSIONAL COMPONENT GLOBAL/TOTAL OUTPATIENT RATE Table Column Headings

*88104 Lab/Pathology

*19030 Also evaluation/management and preventative codes Breast Surgeon

Also evaluation/management and preventative codes Gynecologist

G 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

W W W 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 Manager x x 4161 Carolyn Kerr, Clinical Coordinator x 4160 Deborah Donovan, Quality Assurance Consultant, Eastern Kentucky x 4157 Regina Reid, Quality Assurance Consultant, Western Kentucky CONTACT INFORMATION