The URL can be used to link to this page

Home My WebLink About2013-504 Health - UNC Faculty Physicians for Services in reference to NC Breast & Cervical Cancer Program $6,400 -2 L [Departmental Use Only] TITLE UNC Faculty Physicians FY 2013-14 ORANGE COUNTY CONTRACT UNDER$10,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this day of November, 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 UNC Faculty Physicians (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 'INC BREAST AND CERVICAL CANCER PROGRAM" AND Exhibit B "North Carolina Breast and Cervical Cancer Control Program 2013-14 Fee Schedule",both of which are attached and hereby incorporated by reference. The term of this agreement rendered shall be from July 1, 2013 to June 30,2014. 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. Pam: 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 Six Thousand Four Hundred Dollars, ($6,400) and shall be paid as indicated in Exhibit B. The County shall monitor Services requested to limit Services to those that can be covered by the maximum amount stated in this Agreement. 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. Revised July 2010 1 4. Insurance: Provider, an agency of the State of North Carolina, is responsible for its and its employees' negligence as provided under North Carolina law. Provider shall maintain professional liability self-insurance coverage sufficient to adequately insure itself during the performance of these services. 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 either party upon thirty days' written notice to the other party. 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: 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 Appropriation: 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. ORANG T PROVI By: I By: C unt e ugird,President,UNC Fa lty h sicians 200 S. Cameon St. Attention: Kathryn Grant-Manag d Care Dept. P.O. Box 8181 Post Office Box 168 Hillsborough,NC 27278 Chapel Hill,North Carolina 27514 This inst ment has been approved as to technical content. Colleen Bridger,Orange County r th Director This instrument has been re-audited in the manner required by the Local Government Budget and Fiscal Control Act. Clarence G. Fier,Asst. County Manager/CFO Thi 'n t s een approved as to form and legal sufficiency. Ann tte M.Mo re,Staff Aikomey Revised July 2010 2 EXHIBIT A RE: NC Breast and Cervical Cancer Program This letter outlines the reimbursement terms and conditions whereby UNC Faculty Physicians (UNC FP) will provide services associated with the NC Breast and Cervical Cancer Program as outlined on the "North Carolina Breast and Cervical Cancer Control Program 2013-14 Fee Schedule" (Fee Schedule), attached hereto as Attachment 1. Patients will be referred by the Orange County Health Department (OCHD). Services shall be performed at UNC's clinics located at 101 Manning Drive, Chapel Hill, North Carolina, 27514. All UNC FP physicians performing services under this Agreement shall be Board Eligible or Board Certified OB-GYNs. UNC FP shall comply with State regulations and local medical standards. This letter will cover services provided on dates of service between July 1, 2013 and June 30, 2014. For these services, UNC FP agrees to accept as payment in full reimbursement rates as outlined on the attached Fee Schedule. Hospital charges, if any, are excluded from this agreement, as are any services provided by UNC FP that are not listed on the Fee Schedule. UNC FP further agrees to seek payment only from the OCHD and will not seek payment from individual patients for services covered under this agreement. UNC FP represents that it is in compliance with all applicable Federal, State, and local laws,regulations or orders, as amended or supplemented. The implementation of this contract will be carried out in strict compliance with all Federal, State, or local laws. If applicable, UNC FP shall comply with HIPAA Privacy rules effective April 2003 and HIPAA Security regulations and guidelines effective February 2005. OCHD will notify Lisa Johnson and Jeff Arscott of patients being referred to UNC as part of this program. Identification will occur preferably by email, or otherwise by fax or phone, to: Jeff Arscott, Ambulatory Program Director (919) 966-2687 (phone) (919) 966-6049 (fax) jascott@unch.unc.edu Lisa Johnson, Revenue Cycle Director ' (919) 966-8583 (phone) (919) 966-5790 (fax) Lisa_G_Johnson @unchealthcare.org 2 UNC FP will send invoices to: Orange County Health Department, BCCCP Program Post Office Box 8181 Hillsborough,NC 27278 OCHD agrees to submit payment for these services within thirty (30) business days of the date the invoice is received. Payments should be submitted to: UNC Faculty Physicians Lisa Johnson, Revenue Cycle Director PO Box 168 Chapel Hill,NC 27514 Please send agreement to: UNC Faculty Physicians—Managed Care Dept Attention: Kathryn Grant PO Box 168 Chapel Hill,NC 27514 Exhibit B REF:North Carolina Breast and Cervical Cancer Control Program 2013-14 Fee Schedule For the Period 7/1/13 through 6/30/14 Revised 3/21/2013 13-14 Office Fee Breast Procedures Code Fee Allowed Screening Clinical Breast Examination N/A Yes Screening Mammogram 77057 $ 77.04 No 77057TC $ 44.08 77057-26 $ 32.96 Follow-Up Diagnostic Mammogram-Unilateral 77055 $ 83.98 No 77055TC $ 51.33 77055-26 $ 32.65 Diagnostic Mammogram-Bilateral 77056 $ 107.97 No 77056TC $ 67.10 77056-26 $ 40.87 Sterotactic,localization guidance for breast biopsy or 77031 $ 123.40 No needle placement,each lesion, 77031TC $ 48.18 77031-26 $ 75.23 Mammographic guidance for needle placement, 77032 $ 49.65 No breast,each lesion 77032TC $ 23.58 77032-26 $ 26.07 Radiological examination,surgical specimen 76098 $ 17.90 No 76098TC $ 10.33 76098-26 $ 7.57 Screening Mammogram,Digital,Bilateral G0202 $ 130.02 No G0202TC $ 96.43 G0202-26 $ 33.59 Diagnostic Mammogram,Digital,Bilateral 60204 $ 158.44 No G0204TC $ 116.62 60204-26 $ 41.82 Diagnostic Mammogram,Digital,Unilateral G0206 $ 124.98 No G0206TC $ 91.39 G0206-26 $ 33.59 Ultrasound 76645 $ 85.47 No 76645TC $ 59.85 76645-26 $ 25.63 Surgical Evaluation/Consultation N/A (2) Yes Fine Needle Aspiration 10021 $ 144.29 Yes Fine Needle Aspiration(with imaging guidance) 10022 $ 132.94 Yes Ultrasonic guidance for needle placement,imaging 76942 $ 194.61 No supervision and interpretation(performed in 76942-TC $ 162.98 conjunction with 10022 76942-26 $ 31.63 Cytopathology,evaluation of fine needle aspirate 88172 $ 52.33 No 88172TC $ 17.90 88172-26 $ 34.44 Cytopathology,evaluation of fine needle aspirate 88173 $ 142.15 No >Interpretation and Report 88173TC $ 74.04 88173-26 $ 68.11 Revised: 3/22/12 North Carolina Breast and Cervical Cancer Control Program REF:North Carolina Breast and Cervical Cancer Control Program 2013-14 Fee Schedule Breast Procedures Continued 13-14 Office Fee Code Fee Allowed Needle Core Biopsy 19100 $ 145.24 Yes Puncture Aspiration 19000 $ 106.87 Yes -each additional procedure,use in addition to 19000 19001 $ 25.25 Yes Needle Core Biopsy(open,Incisional) 19101 $ 328.53 Yes Needle Core Biopsy(with imaging guidance) 19102 $ 204.77 Yes Needle Core Biopsy,percutaneous,automated vacuum assist or rotating -biopsy device,using image guidance 19103 $ 529.56 Yes Excision of cyst,fibroadenoma,or other tumor,aberrant breast tissue -duct lesion,nipple or areolar lesion,open, - 1 or more lesions. 19120 $ 469.73 Yes Excision of breast lesion identified by preop placement 19125 $ 521.39 Yes -of radiological marker,open,single lesion. -each additional lesion separately identified by a preop radiological marker(list separately) 19126 $ 151.17 Yes Preoperative placement of needle localization wire,breast 19290 $ 150.44 Yes -each additional lesion(list separately) 19291 $ 64.56 Yes - use with 19290 Image guided placement,metallic localized clip 19295 $ 88.55 Yes (add on code to 19102) Ultrasonic guidance for needle placement, 76942 $ 194.61 No imaging supervision and interpretation 76942-TC $ 162.98 (performed in conjunction with 19102) 76942-26 $ 31.63 Surgical Pathology-Level IV 88305 $ 66.68 No 88305TC $ 30.83 88305-26 $ 35.85 Surgical Pathology-Level V 88307 $ 279.21 No 88307TC $ 199.56 88307-26 $ 79.64 Revised: 3/22/12 North Carolina Breast and Cervical Cancer Control Program REF:North Carolina Breast and Cervical Cancer Control Program 2013-14 Fee Schedule 13-14 Office Fee Cervical Procedures Code Fee Allowed Screening Pelvic Examination-Bimanual N/A Yes Pap Smear Yes 88142 $ 27.85 88141 $ 30.14 88143* $ 27.85 88164 $ 14.53 88174* $ 27.85 88175* $ 27.85 HPV DNA High Risk Typing (3) 87621 $ 33.71 No Follow-Up** (4) Colposcopy 57452 $ 104.65 Yes Colposcopy with Biopsy and endocervical curettage 57454 $ 147.55 Yes Colposcopy with Biopsy 57455 $ 137.64 Yes Colposcopy with endocervical curettage 57456 $ 129.88 Yes Surgical Pathology-Level IV 88305 $ 66.68 No 88305TC $ 30.83 No 88305-26 $ 35.85 No *These procedures(88143,88174,88175)must be reimbursed at the applicable 88142 Medicare reimbursement rate(or less) **Allowable fees for Colposcopy are 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 ees apply and no additional fee is allowed: Colposcopy 57452 $ 88.56 No Colposcopy with Biopsy and endocervical curettage 57454 $ 131.15 No Colposcopy with Biopsy 57455 $ 106.73 No Colposcopy with endocervical curettage 57456 $ 99.60 No Revised: 3/22/12 North Carolina Breast and Cervical Cancer Control Program REF:North Carolina Breast and Cervical Cancer Control Program 2013-14 Fee Schedule Physician Visits Office Visits(2) CPT 12-13 Code Fee New patient,brief 99201 $ 41.56 New patient,limited 99202 $ 70.83 New patient,intermediate 99203 $ 102.72 Established patient,brief 99211 $ 19.29 Established patient,limited 99212 $ 41.56 Established patient,intermediate 99213 $ 69.35 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($21.09)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. (2) All consultations should be billed through the standard"new patient"office visit CPT codes:99201-99205. Consultations billed as 99204 or 99205 must meet the criteria for these codes,and must be pre-authorized. Codes 99204 and 99205 are not appropriate for screening visits. (3) 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 per 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. 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 at the same rate as the Digene Hybrid-Capture 2 HPV DNA Assay. CDC funds cannot be used for reimubrsement of genotyping(e.g.,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. Revised: 3/22/12 NORTH CAROLINA DEPARTMENT OF INSURANCE RISK MANAGEMENT DIVISION f WOQFM ; Wayne Goodwin I Commissioner of Insurance CERTIFICATE OF COVERAGE CERTIFICATE HOLDER: For Information Purposes Only Insurer: State of North Carolina Authorization: Public Officers& Employee Liability Insurance Commission of North Carolina and the General Statutes of North Carolina, Sections §143-291 to§143-305. Period: July 1, 2013 until June 30, 2014 Coverage: A) Tort Claims against Departments, Agencies, and Employees B) Excess Liability for State Employees C) Workers Compensation. Limits A) $1,000,000 for Tort claims against the State B) $10,000,000 for claims against state employees C) Statutory Limits for Workers'Compensation Description: The University of North Carolina-Chapel Hill and its employees, officers, agents, as covered by the Defense of State Employees as per NCGS § 143-300.2. Administrator: Department Insurance-Risk Management Division Public Officers& Employees Liability Insurance Commission 1202 Mail Service Center Raleigh, NC 27699-1202 Note: This Certificate is for informational purposes only and does not alter any provision of the Tort Claims or Defense of State Employees General Statutes of the State. Verified By: Joseph D. Rippard, CPCU Risk Manager UNCH-2013 Cerlificate.doc 1202 Mail Service CenteriRaleigh NC 27699-12021919/661-5880 x234/Fax 919/662-4416