Kentucky Women’s Cancer Screening Program

Local Health Department Individual Provider Contract

TrainingApril 10, 2013

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 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 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 GLOBAL RATE TECHNICAL ONLY PROFESSIONAL ONLY

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.

Contract Rate SheetContracted 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 (Cont.)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

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 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.

Table Column Headings

CPT CODEGLOBAL RATE

TECHNICAL ONLYPROFESSIONAL ONLY

Lab/Pathology87621 8817388104 8817488141 8817588142 8830588143 8830788164 8833188172 88332

Breast Surgeon10021 19100 19125

10022 19101 19126

19000 19102 19290

19001 19103 19291

19030 19120 19295

S0613Also evaluation/management and preventative codes 99201-99396

Gynecologist

57452 57460 57520

57454 57461 57522

57455 57500 58100

57456 57505 58110

Also evaluation/management and preventative codes 99201-99396

Radiologist10021 19102 76645 7705410022 19103 76937 7705519000 19290 76942 7705619001 19291 77031 7705719030 19295 77032 G020219100 76098 77052 G0204

77053 G0206

Anesthesiologist

00400 00940

Hospital

W0166 77057

77052 G0202

77053 G0204

77054 G0206

77055

Services Performed in Hospital

CPT Codes:(00400,00940) anesthesia(10021-19295) breast surgeries(57452-58100) cervical surgeries

Billing for Procedures Performed in Hospitals

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.

    

 Effective. 07/01/2008Revised. 04/01/2013

CPT Code CPT Code DescriptionTechnical

ComponentProfessionalComponent

Total Outpatient Rate Cost Ctr- Minor Obj

00400a Anesthesiology, breast (per unit)     $ 21 813-20510021 Fine needle aspiration without image guidance     $ 138 813-30410022 Fine needle aspiration with image guidance     $ 127 813-30419000 Puncture aspiration of cyst of breast     $ 102 813-304

19001 Puncture aspiration of cyst of breast, each additional cyst, used with CPT code 19000     $ 24

813-304

19100 Breast biopsy, percutaneous, needle core, not using imaging guidance     $ 139 813-304

19101 Breast biopsy, incisional, open     $ 317 813-304

19102Breast biopsy, percutaneous, needle core, using imaging guidance; for placement of localization clip use CPT 19295 

    $ 197 813-304

19103Breast biopsy, percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance 

    $ 506 813-304

19120 Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion; open; one or more lesions 

    $ 457 813-304

19125 Excision of breast lesion identified by preoperative placement of radiological marker; open; single lesion 

    $ 508 813-304

19126 Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker 

    $ 150 813-304

19290 Preoperative placement of needle localization wire, breast     $ 144 813-304

19291Preoperative placement of needle localization wire, breast; each additional lesion 

    $ 62 813-304

19295 Image guided placement, metallic localization clip, percutaneous, during breast biopsy     $ 83 813-304

57452 Colposcopy of cervix, upper/adjacent vagina     $ 102 700-30557454 Colposcopy with biopsy of cervix & endocervical curettage     $ 144 700-30557455 Colposcopy with biopsy of the cervix     $ 134 700-30557456 Colposcopy with endocervical curettage     $ 126 700-305

57460 Endoscopy (Colposcopy) with loop electrode biopsy(s) of the cervix     $ 265 700-305

57461 Endoscopy (Colposcopy) with loop electrode conization of the cervix     $ 299 813-305

Kentucky Women's Cancer Screening Program Approved CPT Codes and Reimbursement Rates for Breast and Cervical Cancer Screening and Follow-up

(Services may be provided either on site or off site as appropriate)

57500 Biopsy, single or multiple, or local excision of lesion, with or without fulguration(separate procedure)

    $ 119 813-305

57505 Endocervical curettage (not done as part of a dilation and curettage)     $ 95 813-305

57520b

Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser 

    $ 286 813-305

57522b Loop electrode excision procedure     $ 248 813-305

58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) 

    $ 102 700-305

58110c

Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure) 

    $ 45 700-305

S0613 Clinical Breast Exam N/A N/A N/A 700-110

77055 Diagnostic mammogram, unilateral $ 48 $ 32 $ 80 813-304/308

77056 Diagnostic mammogram, bilateral $ 63 $ 40 $ 103 813-304/308

77057 Screening Mammogram, Bilateral $ 41 $ 32 $ 73 813-308

G0202 Screening Mammogram, Digital, Bilateral $ 90 $ 33 $ 123 813-308

G0204 Diagnostic Mammogram, Digital, Bilateral $ 109 $ 41 $ 150 813-304/308

G0206 Diagnostic Mammogram, Digital, Unilateral $ 85 $ 33 $ 118 813-304/308

77031 Stereotactic localization guidance for breast biopsy or needle placement $ 45 $ 74 $ 119 813-304

77032 Mammographic guidance for needle placement, breast $ 22 $ 25 $ 47 813-304

76098 Radiologic examination, surgical specimen $ 9 $ 7 $ 16 813-304

76645 Ultrasound, breast (s) unilateral or bilateral, B-scan and/or real time with image documentation $ 64 $ 25 $ 89 813-309

76942 Ultrasonic guidance for needle placement, imaging supervision and interpretation $ 153 $ 31 $ 184 813-304

87621d

Papillomavirus, human, amplified probe Hybrid Capture II from Digene-HPV Test (High Risk Typing, only)Cervista HPV HR

    $ 48

718-305

88141 Conventional Pap test, cervical or vaginal any reporting system, requiring interpretation by physician     $ 29 718-305

88142 Liquid-based Pap test (Thin-Prep)     $ 27 718-305

88143 Pap test, thin layer preparation, automated thin layer preparation manual screening and rescreening     $ 27 718-305

88164 Conventional Pap Test     $ 14 718-250

88172 Cytopathology, evaluation of fine needle aspiration $ 16 $ 33 $ 49 813-304

88173 Cytopathology, interpretation and report of fine needle aspiration $ 69 $ 66 $ 135 813-304

88174 Pap test, thin layer preparation, automated thin layer preparation automated screening     $ 29 718-305

88175 Pap test, thin layer preparation, automated thin layer preparation automated screening and manual rescreening  

    $ 35 718-305

88305Surgical pathology, gross and microscopic examination 

$ 29 $ 35 $ 64 813-304/305

88307Surgical pathology, gross and microscopic examination, requiring microscopic evaluation of margins 

$ 187 $ 78 $ 265 813-305

88331 Pathology consultation during surgery, first tissue block, with frozen section(s), single specimen 

$ 33 $ 58 $ 91 813-305

88332 Pathology consultation during surgery, each additional tissue block with frozen section(s) $ 11 $ 28 $ 39 813-305

99201e Initial-brief evaluation/management     $ 40 700-201

99202e Initial-expanded evaluation/management     $ 68 700-201

99203e Initial-detailed evaluation/management     $ 99 700-201

99204e Initial-comprehensive evaluation/management     $ 153 700-201

99205e Complex-evaluation/management     $ 190 700-201

99211e Subsequent-brief evaluation/management     $ 18 700-201

99212e Subsequent-limited evaluation/management     $ 40 700-201

99213e Subsequent-expanded evaluation/management     $ 67 700-201

99385f Initial preventative medicine evaluation 21 - 39 yrs.     $ 99 700-201

99386f Initial preventative medicine evaluation 40 - 64 yrs.     $ 99 700-201

99395f Periodic preventative medicine evaluation 21 - 39 yrs.     $ 67 700-201

99396f Periodic preventative medicine evaluation 40 - 64 yrs.     $ 67 700-201

W9201 e Initial-brief evaluation/management     $ 40 700

W9202e Initial-expanded evaluation/management     $ 68 700

W9203e Initial-detailed evaluation/management     $ 99 700

W9204e Initial-comprehensive evaluation/management     $ 153 700

W9205e Complex-evaluation/management     $ 190 700

W9211e Subsequent-brief evaluation/management     $ 18 700

W9212e Subsequent-limited evaluation/management     $ 40 700

W9213e Subsequent-expanded evaluation/management     $ 67 700

W9385f Initial preventative medicine evaluation 21 - 39 yrs.     $ 99 700

W9386f Initial preventative medicine evaluation 40 – 64 yrs.     $ 99 700

W9395f Periodic preventative medicine evaluation 21 - 39 yrs.     $ 67 700

W9396f Periodic preventative medicine evaluation 40 - 64 yrs.     $ 67 700

99214g Subsequent-detailed evaluation/management     $ 99 700-201

99215g Subsequent-comprehensive evaluation/management     $ 133 700-201

W9214 g Subsequent-detailed evaluation/management     $ 99 700

W9215g Subsequent-comprehensive evaluation/management     $ 133 700

77052g Computer Aided Detection (CAD) $ 6 $ 2 $ 8  

77053g Ductogram $ 37 $ 16 $ 53 813-304

77054g Ductogram, multiple ducts $ 51 $ 20 $ 71 813-304

00940ag Anesthesiology, vaginal (cervical) procedures (per unit)    

$ 21

813-205

19030g Injection procedure only for ductogram or galactogram     $ 147 813-304

 76937g

Ultrasonic guidance for cyst aspiration (use in conjunction with 19000 or 19001) $ 18 $ 13 $ 31 813-304

88104gh Cytopathology, fluids, washings or brushings (breast) $ 41 $ 27 $ 68 718-304

W0166g Charge for use of hospital room (outpatient)     $ 800 813-311

  

END NOTESa. The KWCSP will reimburse LHDs a maximum of 3 units ($63.00) at the rate $21.00 per unit of anesthesia.

a. Treatment of breast cancer, cervical intraepithelial neoplasia and cervical cancer are not allowed by the Program. Please refer the patients to the Breast and Cervical Cancer Treatment Program (BCCTP) in order for patients to receive treatment services.

a. Use CPT code 58110 in conjunction with 57452, 57454-57456, and 57460-57461. a. HPV Testing:  HPV DNA testing is a reimbursable procedure if used for screening in conjunction with Pap testing or for follow-up of an abnormal Pap result or surveillance as per American

Society for Colposcopy and Cervical Pathology (ASCCP) guidelines. It is not reimbursable as a primary screening test for women of all ages or as an adjunctive screening test to the Pap for women under 30 years of age. Due to the new screening guidelines, co-testing is an option for women 30-64 who meet specific clinical criteria and it will be reimbursed only for those women. For more details

please refer to the cancer section in the Core Clinical Services Guide (CCSG). Local Health Departments (LHDs) should specify the high-risk HPV DNA panel only; reimbursement of screening for low-risk HPV types is not permitted. The program will reimburse Cervista HPV HR, however, only at the same rate as the Digene Hybrid-Capture 2 HPV DNA Assay. KWCSP funds cannot be used for reimbursement of genotyping (e.g., Cervista HPV 16/18). 

a. When this evaluation/management or preventative service is performed in-house by a Registered Nurse, code W920- should be billed instead of 9920- for a new patient and code W921- instead of 9921- for established patients.

a. Office visit CPT codes 99385 and 99386 codes shall be reimbursed at or below the 99203 rate and 99395 and 99396 codes shall be reimbursed at or below the 99213 rate.

a. KWCSP will NOT reimburse LHDs for this procedure. However, LHDs CAN use their state block grants or local tax dollars to reimburse for this procedure.

a. Effective October 1, 2001, this pathology code is not to be used on routine breast cysts (clear fluid/disappears on ultrasound). Only to be used for cases with bloody/abnormal fluid or cysts that does not disappear on ultrasound.

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, Quality Assurance Consultant and 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