1. Kentucky Women’s Cancer Screening Program LHD Individual Provider Contracts Training April 10, 2012

3. Contract 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 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. The link below will take you to the current version of the Kentucky Public Health Practice Reference. The Cancer Screening/Follow-Up Section, found in Volume 1 at this link, is to be utilized by the provider when providing services to cancer screening patients referred by the health department. http://www.chfs.ky.gov/dph/info/dpqi/PHPR.htmhttp://www.chfs.ky.gov/dph/info/dpqi/PHPR.htm

4. Table Column Headings CPT CODE GLOBAL RATE TECHNICAL ONLY PROFESSIONAL ONLY

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 or changes. Changes may be made that require more service from a provider but they must at least cover the minimum requirements listed in the PHPR Cancer Screening Follow-up Section.

6. Lab/Pathology 8762188173 8810488174 8814188175 8814288305 8814388307 8816488331

7. Breast Surgeon 100211910019125 100221910119126 190001910219290 190011910319291 190301912019295 Also evaluation/management and preventative codes 99201-99396 from the PHPR Cancer Screening Follow-up Section approved codes list.

8. Gynecologist 57452574605751057522 57454574615751158100 57455575005751357110 574565750557520 Also evaluation/management and preventative codes 99201-99396 from the PHPR Cancer Screening Follow-up Section approved codes list.

9. Radiologist 77052G02021002219290 77055G02041900019291 77056G02061900119295 770577664519030 770317703219100 760987693719102 769421002119103

10. Anesthesiologist 0040000940

11. Hospital W0166 77052G0202 77055G0204 77057G0206 Additional codes discussed on next two slides

12. Services performed in hospitals CPT codes: 00400, 00940 anesthesia (10021-19295) breast surgeries (57452-58100) cervical surgeries (80000+ codes) labs/pathology are usually billed by the provider performing the service.

13. Billing for Procedures Performed in Hospitals However, if the hospital employs the surgeons and anesthesiologists and pay them salaries, the hospital may bill for the services that these providers perform if the individual providers are not allowed to bill separately. When lab specimens are evaluated at the hospital lab instead of being sent out, the hospital may bill for those 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.