Loading...
HomeMy WebLinkAbout2016-520 Health - UNC Faculty Physicians for services related to BCCCP program abl -sib fmcom [Departmental Use Only] TITLE UNC BCCCP Program FY 2016-17 ORANGE COUNTY CONTRACT UNDER$15,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this first day of July, 2016, ("Effective Date") by and between Orange County, North Carolina, a political subdivision of the State of North Carolina, (the "County"), party of the first part; and UNC Chapel Hill on behalf of its School of Medicine(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 "NC BREAST AND CERVICAL CANCER PROGRAM" and Exhibit B "North Carolina Breast and Cervical Cancer Control Program 2016-17 Services Fee Schedule" and any amendments thereto, both of which are attached and hereby incorporated by reference. The term of this agreement rendered shall be from July 1, 2016 to June 30, 2017. 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 Four Thousand, ($4,000) and at the rate provided in Exhibit B and any amendments thereto. 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 contractor 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 6/16 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 the North Carolina Tort Claims 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, its agents, or assigns directly or indirectly related to the Services to be performed pursuant to this Agreement 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. County may suspend this Agreement upon reasonable notice to the Provider. 7. Entire Agreement and Si atures: 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. 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. 8. Priori : In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms of this Agreement shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Anti-Discrimination Policy. Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 10. Dispute Resolution: Any and all suits or actions to enforce, interpret, or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County,North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 11. 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. [SIGNATURE PAGE TO FOLLOW] Revised 6/16 2 IN WITNESS WHEREOF,County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER By: By: �- County Manager Title:,,, �/� O G d j) 200 S.Cameron St. LJNC Faculty Physicians P.O. Box 8181 PO Box 168 Hillsborough,NC 27278 Chapel Hill,NC 27514 Revised 6/16 3 UNC FACULTY THE UNIVERSITY PHYSICTANS of NORTH CAROLINA At CHAPEL HILL POST OFFICE BOX 168 Exhibit A CHAPEL HILL,NC 27514-0168 NC Breast and Cervical Cancer Program This Letter of Agreement between our respective organizations outlines the reimbursement terms and conditions whereby UNC Faculty Physicians (UNC FP) will provide services related to breast and cervical cancer screening for patients as referred by the Orange County Health Department (OCHD). This letter will cover services provided on dates of service between July 1, 2016 and June 30, 2017. UNC FP shall comply with State regulations and local medical standards. For these services, UNC FP agrees to accept as payment in full reimbursement rates as outlined on the "North Carolina Breast and Cervical Cancer Control Program 2016-2017 Services Fee Schedule" (Fee Schedule) attached hereto as Exhibit B. Hospital services, 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. OCHD and UNC FP agree that UNC FP is an independent contractor and shall not represent itself as an agent or employee of OCHD for any purpose in the performance of UNC FP's duties under this contract. To the extent permitted by the NC Tort Claims Act, the UNC FP shall indemnify and hold harmless the OCHD, its officials, agents, and employees from and against all claims, damages, losses, and expenses, (including but not limited to fees and charges of attorneys and other professionals and costs related to court action or arbitration) arising out of or resulting from the performance of this agreement or the actions of the UNC FP or its officials, employees, or contractors under this agreement. This indemnification shall survive the termination of 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. Either party may terminate this agreement by giving thirty(30) days written notice to the other party. OCHD will notify Ann Hornback of patients being referred to UNC as part of this program. Identification will occur preferably by email, or otherwise phone, to: UNC Hospitals—Gynecology Oncology Clinic Ann Hornback, Nurse Manager * (984) 974-9032 *(984) 974-9673 Ann.Hornback@unchealth.unc.edu UNC FP will send invoices to: Orange County Health Department, BCCCP Program ATTN.Accounts Payable Post Office Box 8181 Hillsborough, NC 2 72 78 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-Integrated Billing Mario Vescio PO Box 168 Chapel Hill, NC 27514 Exhibit B North Carolina Breast and Cervical Cancer Control Program 2016-2017 Services Fee Schedule(1) For the Period 07/01/2016 through 06/30/2017 Revised: 06/08/2016 16-17 Office Fee Breast Procedures Code Fee Allowed Screening Clinical Breast Examination N/A Yes Screening Mammogram 77057 $ 78.38 No 77057TC S 43.56 77057-26 $ 34.82 Follow-Up Diagnostic Mammogram-Unilateral 77055 $ 85.38 No 77055TC S 50.55 77055-26 $ 34.82 Diagnostic Mammogram-Bilateral 77056 $ 109.73 No 77056TC $ 66.54 77056-26 $ 43.18 Radiological examination,surgical specimen 76098 $ 15.94 No 76098TC $ 7.93 76098-26 $ 8.00 Screening Mammogram,Digital,Bilateral 60202 $ 127.00 No G0202TC $ 92.51 G0202-26 S 34.49 Diagnostic Mammogram,Digital,Bilateral 60204 $ 155.34 No G0204TC $ 112.16 G0204-26 $ 43.18 Diagnostic Mammogram,Digital,Unilateral 60206 $ 122.00 No G0206TC $ 87.52 G0206-26 $ 34.49 Ultrasound,complete examination of breast including axilla, 76641 $ 102.77 No unilateral 76641TC $ 66.54 76641-26 $ 36.23 Ultrasound,complete examination of breast including axilla, 76641-50 $ 154.16 No bilateral 76641-TC-50 $ 99.81 76641-26-50 $ 54.35 Ultrasound,limited examination of breast including axilla, 76642 $ 84.66 No unilateral 76642TC $ 50.89 76642-26 $ 33.77 Ultrasound,limited examination of breast including axilla, 76642-50 $ 126.99 No bilateral 76642-TC-50 $ 76.34 76642-26-50 $ 50.66 Surgical Evaluation/Consultation N/A (2) Yes Fine Needle Aspiration 10021 $ 118.41 Yes Fine Needle Aspiration(with imaging guidance) 10022 $ 135.62 Yes Ultrasonic guidance for needle placement,imaging 76942 S 58.66 No supervision and interpretation(performed in 76942-TC $ 25.58 conjunction with 10022 76942-26 $ 33.08 North Carolina Breast and Cervical Cancer Control Program 2016-2017 Services Fee Schedule(1) Breast Procedures Continued 16-17 Office Fee Code Fee Allowed Cytopathology,evaluation of fine needle aspirate 88172 $ 55.50 No 88172TC $ 18.59 88172-26 $ 36.91 Cytopathology,evaluation of fine needle aspirate 88173 $ 147.71 No >Interpretation and Report 88173TC $ 75.47 88173-26 $ 72.24 Puncture Aspiration 19000 $ 108.35 Yes -each additional procedure,use in addition to 19000 19001 $ 26.40 Yes Breast Biopsy(with placement of localization device and imaging of 19081 $ 661.95 Yes biopsy specimen,percutaneous;stereotactic guidance;first lesion)(5) Each additional lesion(5) 19082 $ 545.12 Yes Breast Biopsy(with placement of localization device and imaging of 19083 $ 640.12 Yes biopsy specimen,percutaneous;ultrasound guidance;first lesion)(5) Each additional lesion(5) 19084 $ 524.35 Yes Needle Core Biopsy 19100 $ 144.02 Yes Needle Core Biopsy(open,Incisional) 19101 $ 327.13 Yes Excision of cyst,fibroadenoma,or other tumor,aberrant breast tissue 19120 $ 476.55 Yes -duct lesion,nipple or areolar lesion,open, -1 or more lesions. Excision of breast lesion identified by preop placement 19125 $ 528.54 Yes -of radiological marker,open,single lesion. -each additional lesion separately identified by a preop radiological marker(list separately) 19126 $ 159.12 Yes Placement of breast localization device,percutaneous;mammographic 19281 $ 230.39 Yes guidance;first lesion(6) Each additional lesion(6) 19282 $ 160.42 Yes Placement of breast localization device,percutaneous;stereotactic 19283 $ 258.52 Yes guidance;first lesion(6) Each additional lesion(6) 19284 $ 193.94 Yes Placement of breast localization device,percutaneous;ultrasound 19285 $ 490.09 Yes guidance;first lesion(6) Each additional lesion(6) 19286 $ 429.15 Yes Surgical Pathology-Level IV 88305 $ 70.63 No 88305TC $ 31.91 88305-26 $ 38.72 Surgical Pathology-Level V 88307 $ 294.00 No 88307TC $ 209.00 88307-26 $ 85.00 North Carolina Breast and Cervical Cancer Control Program 2016-2017 Services Fee Schedule(1) 16-17 Office Fee Cervical Procedures Code Fee Allowed Screening Pelvic Examination-Bimanual N/A Yes Pap Smear Yes 88141 $ 31.57 88142 $ 27.60 88143 $ 27.60 88164 $ 14.39 Cytopathology(manual screening and rescreening under Physician supervision) 88165 $ 14.39 88174 $ 29.11 88175 $ 35.40 Human Papillomavirus,hig-risk types(3) 87624 $ 33.41 No Human Papillomavirus,types 16 and 18 only(3) 87625 $ 33.41 No Follow-Up Colposcopy 57452 $ 105.49 Yes Colposcopy with Biopsy and endocervical curettage 57454 $ 148.40 Yes Colposcopy with Biopsy 57455 $ 138.06 Yes Colposcopy with endocervical curettage 57456 $ 130.17 Yes Surgical Pathology-Level IV 88305 $ 70.63 No 88305TC $ 31.91 No 88305-26 $ 38.72 No Physician Visits Office Visits(2) CPT 16-17 Code Fee New patient,brief 99201 $ 41.87 New patient,limited 99202 $ 71.79 New patient,intermediate 99203 $ 103.91 Established patient,brief 99211 $ 19.04 Established patient,limited 99212 $ 41.59 Established patient,intermediate 99213 $ 70.29 00400 Anesthesia Not to exceed 3 Base Units plus Time Units(length of time spent providing anesthesia service in 15 minute increments) minute increments)times Conversion Rate($21.44)or$325,whichever is lower. North Carolina Breast and Cervical Cancer Control Program 2016-2017 Services Fee Schedule(1) 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.Up to two consultation visits may be provided per screening cycle,if indicated. (3) HPV DNA testing is a reimbursable procedure if used for screening in conjunction with Pap testing or for follow-up of an abnormal 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 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 may be used for reimbursement of HPV genotyping (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) Codes 19081-19084 are to be used for breast biopsies that include image guidance,placement of localization device,and imaging of specimen.These codes should not be used in conjunction with 19280-19286. (6) Codes 19281-19286 are for image guidance placement of localization device without image-guided biopsy.These codes should not be used in conjunction with 19081-19084. North Carolina Breast and Cervical Cancer Control Program Maximum Allowable Fees-WISEWOMAN For the Period 07/01/2016-06/30/2017 Revised: 05/26/2016 Reviewed 06/08/2016 Procedures CPT Code Fee Automated Lipid Panel * 80061 $ 18.24 Lipid Panel(CLIA waived)] 80061QW $ 18.24 Cholesterol,Total Serum 82465 $ 5.92 Cholesterol, Total Serum(CLIA waived) 82465QW $ 5.92 Lipoprotein(HDL) 83718 $ 11.16 Lipoprotein(HDL)(CLIA waived) 83718QW $ 11.16 Glucose,blood,quantitative 82947 $ 5.35 Glucose,blood,quantitative(CLIA waived) 82947QW $ 5.35 Glucose,blood,reagent strip 82948 $ 4.32 Glucose,tolerance test,three specimens 82951 $ 17.53 Glucose,tolerance test,three specimens(CLIA waived) 82951QW $ 17.53 Hemoglobin A I C 83036 $ 13.22 Hemoglobin A I C (CLIA waived) 83036QW $ 13.22 Basic Metabolic Profile ** 80048 $ 10.92 Basic Metabolic Profile(CLIA waived)** 80048QW $ 10.92 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 $ 41.87 New Patient,Limited 99202 $ 71.79 New Patient,Intermediate 99203 $ 103.91 New Patient,Limited(Comprehensive) 99204 $ 159.32 New Patient,Intermediate(Comprehensive) 99205 $ 200.06 Established Patient,Brief 99211 $ 19.04 Established Patient,Limited 99212 $ 41.59 Established Patient,Intermediate 99213 $ 70.29 Note: Office 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 LDL)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.