Loading...
HomeMy WebLinkAbout2013-128 Health - Wake Radiology Diagnostic Imagin for Scope of Services - Breast and Cervical Cancer Control Program $ N/A [Departmental Use Only] TITLE Wake Radiology BCCCP FY 2012-13 ORANGE COUNTY CONTRACT UNDER$10,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 1St day of MAY, 2013, ("Effective Date") by and between Orange County, North Carolina, a body politic and corporate organized under the laws of the State of North Carolina, (the "County"), party of the first part; and Wake Radiology Diagnostic Imaging, LLC(the "Provider"),party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement,time being of the essence: The services and/or materials (hereinafter referred to collectively as "Services") to be furnished under this Agreement are as follows: See Exhibit A "Scope of Services" AND Exhibit B "North Carolina Breast and Cervical Cancer Control Program 2013-4 Fee Schedule, both of which are attached and hereby incorporated by reference. The term of this agreement rendered shall be from May 1, 2013 to June 30,2013. Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement,without the prior written approval of the County. SPECIFIC TERMS 1. Pae: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed Five Thousand Four Hundred Dollars, ($5,400) and shall be paid as indicated in Exhibit B. Payment shall be made within thirty(30) days of an invoice properly submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. 2. Non—waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non-Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent Provider, and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: The Provider shall obtain, at its sole expense, all insurance needed to adequately insure itself during the performance of these services as required by the County's Risk Management Policy. Revised July 2010 1 5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) to the extent provided by North Carolina Torts Claim Act arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. 7. Entire Agreement: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. Modifications may be evidenced by telefacsimile signature. 8. Governing Law:aw: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina. Should either party initiate litigation to settle any dispute involving the terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in Orange County,North Carolina. 9. Non Appro riation: Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. IN WITNESS WHEREOF,Orange County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER By: By: Fr . Clifto Jr., ounty Manager Robert E. chaaf, ,President 200 S. Cameron S Attention: Chuck W1cox. P.O. Box 8181 3949 Browning Place Hillsborough,NC 27278 Raleigh,NC 27609 This ' strument has been approved as to technical content. Co leen Bridger, Orange C ealth Director This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act. 1; 'd, I Clarence G. Grier,Asst. County Manager/CFO Thi n ru t as been approved as to form and legal sufficiency. Anne e M.Moore, Staf Attorney Revised July 2010 2 EXHIBIT A SCOPE OF SERVICES The Centers for Disease Control has awarded funds to the North Carolina Department of Environment, Health and Natural Resources to provide mammography services, which then awarded funds to the Orange County Health Department"OCHD"to assure the provision of services at the local level. With the funds awarded it is necessary for OCHD to contract with a facility for the provision of mammography services, and the Centers for Disease Control has mandated certain standardized requirements, therefore, the Wake Radiology Diagnostic Imaging, LLC ("Wake Radiology") agree to provide the following services: A. Wake Radiology agrees to: 1. Provide screening and repeat mammograms to include 2 views of each breast in asymptomatic women. 2. Provide ultrasound if recommended after diagnostic mammogram. 3. Provide diagnostic mammography for women over 40 years of age who are referred by the clinician because of abnormal findings on clinical breast examinations or for women who have abnormal screening mammograms. 4. Provide fine needle aspiration with imaging guidance if ordered by breast surgeon. 5. Provide needle core biopsy with imaging guidance if ordered by breast surgeon. 6. Provide documentation of current mammography accreditation by having the American College of Radiology(ACR), or documentation of having submitted a completed application for ACR accreditation. Accreditation must be granted within six months of the start of this contract. 7. Provide documentation of certification by the Federal Health Care Financing Administration to provide screening mammography services. 8. See clients referred by the OCHD for an initial screening mammogram within six weeks and perform repeat diagnostic mammography for clients with symptoms whose screening mammograms indicate the need for further evaluation within two weeks. 9. Report the mammography results to the OCHD using the lexicon recommended by ACR. a. For results that are "Normal"on a screening or repeat mammogram and"Negative" or"Benign" on a diagnostic mammogram shall send a report by mail within two weeks. b. For abnormal mammograms,the Provider shall notify the OCHD by phone within three days and written report within one week. 10. The provider is prohibited from billing clients for any additional charges 11. All parties to the contract agree to abide by all laws and regulations governing the confidentiality of patient information, and further agree to vigorously safeguard privilege information. North Carolina Breast and Cervical Cancer Control Program 2012-2013 Services Fee Schedule(1) For the Period 7/1/12 through 6/30/13 Revised 3/22/2012 12-13 Office Fee Breast Procedures Code Fee Allowed Screening Clinical Breast Examination N/A Yes Screening Mammogram 77057 $ 76.76 No 77057TC $ 43.46 77057-26 $ 33.29 Follow-Up Diagnostic Mammogram-Unilateral 77055 $ 82.75 No 77055TC $ 49.46 77055-26 $ 33.29 Diagnostic Mammogram-Bilateral 77056 $ 105.81 No 77056TC $ 64.60 77056-26 $ 41.21 Sterotactic,localization guidance for breast biopsy or 77031 $ 138.29 No needle placement,each lesion, 7703 ITC $ 62.40 77031-26 $ 75.89 . Mammographic guidance for needle placement, 77032 $ 51.24 No breast,each lesion 77032TC $ 24.85 77032-26 $ 26.40 Radiological examination,surgical specimen 76098 $ 17.59 No 76098TC $ 10.02 76098-26 $ 7.58 Screening Mammogram,Digital,Bilateral G0202 $ 76.76 No 60202TC $ 43.46 G0202-26 $ 33.29 Diagnostic Mammogram,Digital,Bilateral 00204 $ 105.81 No G0204TC $ 64.60 G0204-26 $ 41.21 Diagnostic Mammogram,Digital,Unilateral G0206 $ 82.75 No G0206TC $ 49.46 00206-26 $ 33.29 Ultrasound 76645 $ 83.93 No 76645TC $ 58.29 76645-26 $ 25.64 Surgical Evaluation/Consultation N/A (2) Yes Fine Needle Aspiration 10021 $ 137.10 Yes Fine Needle Aspiration(with imaging guidance) 10022 $ 128.89 Yes Ultrasonic guidance for needle placement,imaging 76942 $ 192.80 No supervision and interpretation(performed in 76942-TC $ 160.84 conjunction with 10022 76942-26 $ 31.96 Cytopathology,evaluation of fine needle aspirate 88172 $ 50.46 No 88172TC $ 17.59 88172-26 $ 32.87 Cytopathology,evaluation of fine needle aspirate 88173 $ 131.79 No >Interpretation and Report 88173TC $ 65.87 88173-26 $ 65.93 Revised:3/22/12 North Carolina Breast and Cervical Cancer Control Program 2012-2013 Services Fee Schedule(1) Breast Procedures Continued 12-13 Office Fee Code Fee Allowed Needle Core Biopsy 19100 $ 138.36 Yes Puncture Aspiration 19000 $ 103.13 Yes -each additional procedure,use in addition to 19000 19001 $ 24.94 Yes Needle Core Biopsy(open,Incisional) 19101 $ 315.74 Yes Needle Core Biopsy(with imaging guidance) 19102 $ 199.81 Yes Needle Core Biopsy,percutaneous,automated vacuum assist or rotating -biopsy device,using image guidance 19103 $ 513.69 Yes Excision of cyst,fibroadenoma,or other tumor,aberrant breast tissue -duct lesion,nipple or areolar lesion,open, - 1 or more lesions. 19120 $ 453.20 Yes Excision of breast lesion identified by preop placement 19125 $ 502.68 Yes -of radiological marker,open,single lesion. each additional lesion separately identified by a preop radiological marker(list separately) 19126 $ 150.60 Yes Preoperative placement of needle localization wire,breast 19290 $ 150.19 Yes -each additional lesion(list separately) 19291 $ 63.96 Yes - use with 19290 Image guided placement,metallic localized clip 19295 $ 84.48 Yes (add on code to 19102) Ultrasonic guidance for needle placement, 76942 $ 192.80 No imaging supervision and interpretation 76942-TC $ 160.84 (performed in conjunction with 19102) 76942-26 $ 31.96 Surgical Pathology-Level IV 88305 $ 99.84 No 88305'T'C $ 64.60 88305-26 $ 35.23 Surgical Pathology-Level V 88307 $ 220.96 No 88307TC $ 144.12 88307-26 $ 76.84 Revised:3/22/12 North Carolina Breast and Cervical Cancer Control Program 2012-2013 Services Fee Schedule(1) 12-13 Office Fee Cervical Procedures Code Fee Allowed Screening Pelvic Examination-Bimanual N/A Yes Pap Smear Yes 88142 $ 28.70 88141 $ 27.94 88164 $ 14.97 88174* $ 28.70 88175* $ 28.70 1-IPV DNA High Risk Typing (3) 87621 $ 34.73 No Follow-Up** (4) Colposcopy 57452 $ 103.75 Yes Colposcopy with Biopsy and endocervical curettage 57454 $ 146.99 Yes Colposcopy with Biopsy 57455 $ 136.75 Yes Colposcopy with endocervical curettage 57456 $ 129.31 Yes Surgical Pathology-Level IV 88305 $ 99.84 No 88305TC $ 64.60 No 88305-26 $ 35.23 No *These procedures(88174,88175)must be reimbursed at the applicable 88142 Medicare reimbursement rate(or less) **Allowable fees for Colposcopy arc for the procedure performed in a physician's office or a similar facility. If Colposcopy is done in a hospital as an outpatient procedure or in an ambulatory surgery center,the following fees apply and no additional fee is allowed: Colposcopy 57452 $ 87.97 No Colposcopy with Biopsy and endocervical curettage 57454 $ 130.89 No Colposcopy with Biopsy '57455 $ 106.78 No Colposcopy with endocervical curettage 57456 $ 99.65 No Revised:3/22/12 North Carolina Breast and Cervical Cancer Control Program 2012-2013 Services Fee Schedule(1) Physician Visits Omce Visits(5) CPT 12-13 Code Fee New patient,brief 99201 $ 40.32 New patient,limited 99202 $ 68.97 New patient,intermediate 99203 $ 99.92 Established patient,brief 99211 $ 18.67 Established patient,limited 99212 $ 40.32 Established patient,intermediate 99213 $ 67.17 00400 Anesthesia Not to exceed 3 Base Units plus Time Units(length of time spent providing anesthesia service in 15 minute increments)times Conversion Rate($20.61)or$250,whichever is lower. Global and Split Fees Both global and split fees apply to the breast procedures listed on page 1 of this fee schedule. The method and direction of payment will determine their usage for your facility. The following are the codes and definitions that apply: G=Global;the all-inclusive fee for performing and interpreting the service. TC=Technical Component;the fee for performing the service. 26=Professional Component;the fee for interpreting the service. Notes: (1) NC BCCCP covers only the physician's fee. Any facility charges associated with these CPT codes are not covered. (Z) Use office visit codes for these services. Consultation codes have been discontinued. (3) HPV DNA testing is a reimbursable procedure if used in the fallow-up of an ASC-US result from the screening exam, or for surveillance at one year following an LSIL Pap test and no CIN2,3 on colposcopy-directed biopsy. It is not reimbursable as a primary screening test or as an adjunctive screening test to the Pap. Providers should specify the high-risk HPV DNA panel only;reimbursement of screening for low-risk HPV types is not permitted. The CDC will allow for reimbursement of Cervista HPV HR,however,only at the same rate as the Digene Hyrid- Capture 2 HPV DNA Assay.CDC funds cannot be used for reimbursement of Cervista HPV 16/18. (4) Up to three cervical biopsies,including ECC(endocervical currettage),per colposcopy will be covered by the BCCCP when the appropriate algorithm is followed. Each specimen container is counted as one biopsy. Under no circumstances are endometrial or vaginal biopsies covered by the BCCCP. (5) Effective January 1,2010,Consultation Visit codes 99241 through 99255 have been eliminated. Codes 99201,99202, and 99203 are to be used in their place. Revised:3/22/12