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Home My WebLink About2014-526 Health - Wake Radiology Diagnostic Imaging, Inc. to provide x-ray services to patients referred by the OCHD $6,400 Cb1� [Departmental Use Only] TITLE Wake Radiology BCCCP FY 2014-15 ORANGE COUNTY CONTRACT UNDER $10,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this ls` day of July, 2015, ("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 Cervica Cancer Control Program 2014-15 Fee Schedule", both of which are attached and hereby incorporated by reference. The term of this agreement rendered shall be from July 1,2014 to June 30,2015. 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. Payment: 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. 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. Indemni : 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: 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. 10. Si matures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11 A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,Orange County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER /J By: By: wk /, fir- _ Bonnie Hammersley, County Man r -D-hert rt r. °-' -°r MT',Pres' ent 4-gLdcsri Tord., .�-. 200 S. Cameron St. Attention: Chuck Wilcox m P.O. Box 8181 3949 Browning Place Hillsborough,NC 27278 Raleigh,NC 27609 This ins r ent has been approved as to technical content. Colleen Bridger,MPH,PhD,O ge County Health Director This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act. a4-,6-ct, /J. Avc- Clarence G. Grier,Asst. County Manager/CFO Revised July 2010 2 This in gmas been ap proved as to form and legal sufficiency. i Anne M , Staff Atto ey Revised July 2010 3 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 aspir-alion with imaging guidanee if ordered b bfe s4 swgeoR. S. Pro'dinz°-_arm 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. REF: North Carolina Breast and Cervical Cancer Control Program Exhibit B North Carolina Breast and Cervical Cancer Control Program 2014-2015 Services Fee Schedule(1) For the Period 07/01/2014 through 06/30/2015 Revised: 04/10/2014 14-15 Office Fee Breast Procedures Code Fee Allowed Screening Clinical Breast Examination N/A Yes Screening Mammogram 77057 $ 58.98 No 77057TC $ 33.05 77057-26 $ 25.93 Follow-Up Diagnostic Mammogram-Unilateral 77055 $ 64.29 No 77055TC $ 38.36 77055-26 $ 25.93 Diagnostic Mammogram-Bilateral 77056 $ 82.64 No 77056TC $ 50.49 77056-26 $ 32.15 Radiological examination, surgical specimen 76098 $ 13.74 No 76098TC $ 7.78 76098-26 $ 5.96 Screening Mammogram, Digital,Bilateral G0202 $ 95.87 No G0202TC $ 70.20 G0202-26 $ 25.68 Diagnostic Mammogram,Digital,Bilateral G0204 $ 117.01 No G0204TC $ 84.85 G0204-26 $ 32.15 Diagnostic Mammogram,Digital,Unilateral G0206 $ 92.08 No G0206TC $ 66.40 G0206-26 $ 25.68 Ultrasound 76645 $ 70.91 No 76645TC $ 50.74 76645-26 $ 20.17 Surgical Evaluation/Consultation N/A (2) Yes Fine Needle Aspiration 10021 $ 106.60 Yes Fine Needle Aspiration(with imaging guidance) 10022 $ 100.45 Yes Ultrasonic guidance for needle placement,imaging 76942 $ 52.88 No supervision and interpretation(performed in 76942-TC $ 28.25 conjunction with 10022 76942-26 $ 24.63 Cytopathology,evaluation of tine needle aspirate 88172 $ 39.17 No 89172TC $ 12.83 88172-26 $ 26.33 Cytopathology,evaluation of line needle aspirate 88173 $ 105.08 No >Interpretation and Report 88173TC $ 52.76 88173-26 $ 52.32 REF: North Carolina Breast and Cervical Cancer Control Program Exhibit B North Carolina Breast and Cervical Cancer Control Program 2014-2015 Services Fee Schedule(1) Breast Procedures Continued 14-15 Office Fee Code Fee Allowed Needle Core Biopsy 19100 $ 106.89 Yes Puncture Aspiration 19000 $ 80.31 Yes -each additional procedure,use in addition to 19000 19001 $ 19.46 Yes Needle Core Biopsy(open, lncisional) 19101 $ 241.43 Yes Breast Biopsy(with placement of localization device and imaging of 19081 $ 481.33 Yes biopsy specimen. percutaneous; stereotactic guidance;first lesion)(5,7,9) Each additional lesion(5,7,9) 19082 $ 389.42 Yes Breast Biopsy(with placement of localization device and imaging of 19083 $ 478.19 Yes biopsy specimen,percutaneous; ultrasound guidance;first lesion)(5,9) Each additional lesion(5,9) 19084 $ 384.10 Yes Excision of cyst, fibroadenoma,or other tumor,aberrant breast tissue -duct lesion,nipple or areolar lesion,open, - I or more lesions. 19120 $ 351.46 Yes Excision of breast lesion identified by preop placement 19125 $ 389.73 Yes -of radiological marker,open,single lesion. -each additional lesion separately identified by a preop radiological marker(list separately) 19126 $ 116.69 Yes Placement of breast localization device,percutaneous;mammographic 19281 $ 174.83 Yes guidance;first lesion(6,8,9) Each additional lesion(6,8,9) 19282 $ 121.37 Yes Placement of breast localization device,percutaneous; stereotactic 19283 $ 198.33 Yes guidance; first lesion(6,7,9) Each additional lesion(6,7,9) 19284 $ 145.38 Yes Placement of breast localization device,percutaneous; ultrasound 19285 $ 334.32 Yes guidance;first lesion(6.9) Each additional lesion(6,9) 19286 $ 280.13 Yes Ultrasonic guidance for needle placement, 76942 $ 52.88 No imaging supervision and interpretation 76942-TC $ 28.25 (performed in conjunction with 19102) 76942-26 $ 24.63 Surgical Pathology-Level IV 88305 $ 50.61 No 88305TC $ 22.69 88305-26 $ 27.92 Surgical Pathology-Level V 88307 $ 205.14 No 88307TC $ 143.98 88307-26 $ 61.16 North Carolina Breast and Cervical Cancer Control Program 2014-2015 Services Fee Schedule(1) 14-15 Office Fee Cervical Procedures Code Fee Allowed Screening Pelvic Examination-Bimanual N/A Yes Pap Smear Yes 88142 $ 27.64 88141 $ 22.85 88143* $ 27.64 88164 $ 14.42 Cytopathology(manual screening and rescreening under Physician supery 88165 $ 14.42 88174* $ 27.64 88175* $ 27.64 HPV DNA High Risk Typing (3) 87621 $ 33.46 No Follow-Up** (4) Colposcopy 57452 $ 79.48 Yes Colposcopy with Biopsy and endocervical curettage 57454 $ 112.42 Yes Colposcopy with Biopsy 57455 $ 104.38 Yes Colposcopy with endocervicat curettage 57456 $ 98.75 Yes Surgical Pathology- Level IV 88305 $ 50.61 No 88305TC $ 22.69 No 88305-26 $ 27.92 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 apply and no additional fee is allowed: Colposcopy 57452 $ 67.86 No Colposcopy with Biopsy and endocervical curettage 57454 $ 100.80 No Colposcopy with Biopsy 57455 $ 82.40 No Colposcopy with endocervical curettage 57456 $ 76.77 No Physician Visits Office Visits(2) CPT 14-15 Code Fee New patient, brief 99201 $ 30.96 New patient,limiter{ 99202 $ 53.35 New patient,intermediate 99203 $ 77.39 Established patient,brief 99211 $ 14.32 Established patient,limited 99212 $ 31.21 Established patient,intermediate 99213 $ 52.39 00400 Anesthesia Not to exceed 3 Base Units plus Time Units(length of time spent providing anesthesia service in 15 increments) minute increments) times Conversion Rate($16.33)or$250,whichever is lower. REF: North Carolina Breast and Cervical Cancer Control Program Exhibit B North Carolina Breast and Cervical Cancer Control Program 2014-2015 Services Fee Schedule(1) Global and Split Fees Both global and split fees apply to the breast procedures listed on page I 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: (n 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. (a) 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 reimbbrsement 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. (5) CPT codes 19081 - 19084 replace codes 19102 and 19103. (a) CPT codes 19281 - 19286 replace codes 19290 and 19291. m CPT codes 19081, 19082, 19283, and 19284 replace code 77031. (8) CPT codes 19281 and 19282 replace code 77032. (9) CPT codes 19081 - 19084 and 19281 - 19286 replace code 19295. f REF: North Carolina Breast and Cervical Cancer Control Program Exhibit B North Carolina Breast and Cervical Cancer Control Program Maximum Allowable Fees- WISEWOMAN For the Period 07/01/2014 -06/30/2015 Procedures Revised: 04/10/2014 Automated Lipid Panel * CPT Code Fee Lipid Panel (CLIA waived)' 80061 $ 18.27 Cholesterol,Total Serum 80061QW $ 18.27 Cholesterol,Total Serum(CLIA waived) 82465 $ 5.93 Lipoprotein(HDL) 82465QW $ 5.93 Lipoprotein (HDL)(CLIA waived) 83718 $ 1 1.17 Glucose,blood,quantitative 83718QW $ 11.17 Glucose, blood,quantitative(CLIA waived) 82947 $ 5.36 Glucose, blood, reagent strip 82947QW $ 5.36 Glucose, tolerance test,three specimens 82948 $ 4.32 Glucose, tolerance test, three specimens(CLIA waived) 82951 $ 17.56 Hemoglobin A1C 82951QW $ 17.56 Hemoglobin A I C(CLIA waived) 83036 $ 13.24 83036QW $ 13.24 Basic Metabolic Profile ** 80048 $ 10.94 Other Routine venipuncture 36415 $ 3.00 Education and Training for Patient Self-Management Individual, Face-to-face, 30 minutes 98960 $ 30.00 Group, Face-to-face, 30 minutes 98961 $ 30.00 Individual, Phone, 15 minutes 98967 $ 15.00 Office Visits New Patient, Brief 99201 $ 30.96 New Patient, Limited 99202 $ 53.35 New Patient, Intermediate 99203 $ 77.39 New Patient, Limited(Comprehensive) 99204 $ 119.11 New Patient, Intermediate(Comprehensive) 99205 $ 148.63 Established Patient, Brief 99211 $ 14.32 Established Patient,Limited 99212 $ 31.21 Established Patient,Intermediate 99213 $ 52.39 Note: Office Visits or Consultation Visits listed above may be used to reimburse for consultations associated with WISEWOMAN referrals, when applicable. *Lipid Panel tests are: Total Serum Cholesterol, Lipoprotein (HDL)and Triglycerides. **Basic Metabolic Collection Container: 1 mL Serum/One SST Remarks: Includes NA, K,CL, CO2, Profile GLUC, BUN, CREA, CA The Clinical Laboratory Improvement Amendments of 1988 (CLIA)law specifies that laboratory requirements be based on the complexity of the test performed and established provisions for categorizing a test as waived. Tests may be waived from regulatory oversight if they meet certain requirements established by the statute. CLIA waived tests employ methodologies that are so simple and accurate as to render the likelihood of erroneous results negligible; pose no reasonable risk of harm to the patient if the test is performed incorrectly; and/or are cleared by the Food and Drug Administration for home use. 2 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. Medical Mutual` — -------■-� PaoTlrmuc 001 PROSSS§40* CERTIFICATE OF INSURANCE, This certificate is issued as a matter of information only and confers no rights upon the certificate bolder. This certificate does not amend,extend or alter the coverage afforded by the policies listed below. INSURED: Wake Radiology Consultants PA Attn: Accounts Payable PO Box 19366 Raleigh,NC 27619 COMPANY AFFORDING COVERAGE: Medical Mutual Insurance Company of North Carolina 700 Spring Forest Road 4th Floor Raleigh,NC 27609 TYPE OF INSURANCE: Claims-Made Professional Liability POLICY NUMBER:PGl 12094 RETROACTIVE DATE:April 6, 1976 POLICY PERIOD: FROM: October 1,2014;12:01 A.M. TO:October 1,2015;12:01 A.M. LIMITS OF LIABILITY: EACH CLAIM ANNUAL AGGREGATE 6,000,000 8,000,000 Date: August 07.2014 Authori epresentative CERTIFICATE HOLDER- Wake Radiology Diagnostic Imaging Inc OCT 2 4 2014 3614 Haworth Dr . Raleigh,NC 27609 By— MEDICAL MUTUAL INSURANCE COMPANY PM0901NC(06108) OF NORTH CAROLINA DINKINL