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

3. 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

4. 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.)

5. 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

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

7. 8762188173 8814188174 8814288175 8814388305 8816488307 8816588331 8817288332 *88104 Lab/Pathology

8. 10021 190821910119283 10022 190831912019284 19000 190841912519285 19001 190851912619286 19081 190861928119287 191001928219288 *19030 Also evaluation/management and preventative codes 99201-99396 Breast Surgeon

9. 57452 5746057520 57454 5746157522 57455 5750058100 57456 5750558110 Also evaluation/management and preventative codes 99201-99396 Gynecologist

10. 7609877055 7664577056 7694277057 7705377058 G0202 77059 G0204 G0206 *76937, *77052, *77054 Radiologist

11. 00400 *00940 Anesthesiologist

12. 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

13. 0094099214 1903099215 76937W0166 77052W9214 77054W9215 88104 Procedures that can be paid with state preventive block grant funds or other sources but cannot be reimbursed with KWCSP federal funds.

14. Deleted and New CPT Codes

15. 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 CONTACT INFORMATION