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Home My WebLink About2017-388 Health - UNC Health Care System for BCCCP mammogram screenings Peo, I*_ [Departmental Use Only] TITLE UNC BCCCP Program FY 2017-18 ORANGE COUNTY CONTRACT UNDER$15,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this first day of July, 2017, ("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 Health Care System(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 2017 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 1,2017 to June 30,2018. 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 6/17 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 Signatures: 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 I IA and Article 40 of North Carolina General Statute Chapter 66. 8. Priority: 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. Governin Law.aw. 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 6/17 2 IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PROVIDER: By: By: Bonnie Hammersley, County Mana J n Lewis, Chief Financial Officer Printed Name and Title {ood�kSVMN 61 UNC FACULTY , �„ (j .✓,... THE UNIVERSITY Of NORTH CAROLINA UNC HEALTH CARE at CHAPEL HILL POST OFFICE BOX 168 Exhibit A CHAPEL HILL,NC 27514-0[68 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, 2017 and June 30, 2018. 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 2017-2018 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 P (984) 974-9032 F(984) 9 74-96 73 Ann.Hornback@unchealth.unc.edu UNC FP will send invoices to: Orange County Health Department, BCCCP Program A7TN: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 2017 Services Fee Schedule(1) For the Period 01/01/2017 through 12/31/2017 Revised: 01/11/2017 2017 Office Fee Breast Procedures Code Fee Allowed Screening Clinical Breast Examination N/A Yes Screening Digital Breast Tomosynthesis(2) 77063 $ 53.72 No 77063TC $ 23.72 77063-26 $ 30.01 Screening Mammogram,Digital,Bilateral G0202 $ 130.16 No G0202TC $ 93.48 G0202-26 $ 36.68 Follow-Up Radiological examination,surgical specimen 76098 $ 15.96 No 76098TC $ 7.95 76098-26 $ 8.01 Diagnostic Mammogram,Digital,Bilateral G0204 $ 161.35 No G0204TC $ 113.20 G0204-26 $ 48.16 Diagnostic Mammogram,Digital,Unilateral G0206 $ 127.21 No G0206TC $ 88.47 G0206-26 $ 38.74 Diagnostic Digital Breast Tomosynthesis(3) G0279 $ 53.73 No G0279TC $ 23.72 G0279-26 $ 30.01 Ultrasound,complete examination of breast including axilla, 76641 $ 103.36 No unilateral 76641TC $ 67.09 76641-26 $ 36.27 Ultrasound,complete examination of breast including axilla, 76641-50 $ 155.04 No bilateral 76641-TC-50 $ 100.64 76641-26-50 $ 54.40 Ultrasound,limited examination of breast including axilla, 76642 $ 85.19 No unilateral 76642TC $ 51.38 76642-26 $ 33.81 Ultrasound,limited examination of breast including axilla, 76642-50 $ 127.79 No bilateral 76642-TC-50 $ 77.07 76642-26-50 $ 50.72 Surgical Evaluation/Consultation N/A (7) Yes Fine Needle Aspiration 10021 $ 117.87 Yes Fine Needle Aspiration(with imaging guidance) 10022 $ 135.87 Yes Ultrasonic guidance for needle placement,imaging 76942 $ 58.51 No supervision and interpretation 76942-TC $ 26.32 76942-26 $ 32.18 N.C.Department of Health and Human Services,Division of Public Health, Page 1 Chronic Disease and Injury Section,Cancer Prevention and Control Branch 2/2017 North Carolina Breast and Cervical Cancer Control Program 2017 Services Fee Schedule(1) Breast Procedures Continued 2017 Office Fee Code Fee Allowed Cytopathology,evaluation of fine needle aspirate 88172 $ 55.62 No 88172TC $ 18.64 88172-26 $ 36.98 Cytopathology,evaluation of fine needle aspirate 88173 $ 148.09 No >Interpretation and Report 88173TC $ 75.70 88173-26 $ 72.39 Puncture Aspiration 19000 $ 108.21 Yes -each additional procedure,use in addition to 19000 19001 $ 26.41 Yes Breast Biopsy(with placement of localization device and imaging of 19081 $ 661.72 Yes biopsy specimen,percutaneous;stereotactic guidance;first lesion)(4) Each additional lesion(4) 19082 $ 544.34 Yes Breast Biopsy(with placement of localization device and imaging of 19083 $ 641.75 Yes biopsy specimen,percutaneous;ultrasound guidance;first lesion)(4) Each additional lesion(4) 19084 $ 523.26 Yes Needle Core Biopsy 19100 $ 144.08 Yes Needle Core Biopsy(open,Incisional) 19101 $ 326.89 Yes Excision of cyst,fibroadenoma,or other tumor,aberrant breast tissue 19120 $ 475.51 Yes -duct lesion,nipple or areolar lesion,open, - 1 or more lesions. Excision of breast lesion identified by preop placement 19125 $ 527.04 Yes -of radiological marker,open,single lesion. -each additional lesion separately identified by a preop radiological marker(list separately) 19126 $ 158.70 Yes Placement of breast localization device,percutaneous;mammographic 19281 $ 231.54 Yes guidance;first lesion(5) Each additional lesion(5) 19282 $ 159.87 Yes Placement of breast localization device,percutaneous;stereotactic 19283 $ 260.73 Yes guidance;first lesion(5) Each additional lesion(5) 19284 $ 195.08 Yes Placement of breast localization device,percutaneous;ultrasound 19285 $ 493.16 Yes guidance;first lesion(5) Each additional lesion(5) 19286 $ 428.81 Yes Surgical Pathology-Level IV 88305 $ 66.46 No gross and microscopic examination 88305TC $ 27.66 88305-26 $ 38.80 Surgical Pathology-Level V 88307 $ 254.77 No gross and microscopic examination, 88307TC $ 169.26 requiring microscopic evaluation of surgical margins 88307-26 $ 85.51 Cervical Procedures continued on next page N.C.Department of Health and Human Services,Division of Public Health, Page 2 Chronic Disease and Injury Section,Cancer Prevention and Control Branch 2/2017 North Carolina Breast and Cervical Cancer Control Program 2017 Services Fee Schedule(1) 2017 Office Fee Cervical Procedures Code Fee Allowed Screening Pelvic Examination-Bimanual N/A Yes Yes Cytopathology,cervical or vaginal, requiring interpretation 88141 $ 31.64 by physician Cytopathology(liquid based Pap test)cervical or vaginal,collected 88142 $ 27.79 in preservative fluid,automated thin layer preparation;manual screening under physician supervision Cytopathology(liquid based Pap test)cervical or vaginal,collected 88143 $ 27.79 in preservative fluid,automated thin layer preparation;manual screening and rescreening under physician supervision Cytopathology(conventional Pap test),slides cervical or vaginal, 88164 $ 14.49 manual screening under physician supervision Cytopathology(conventional Pap test),slides cervical or vaginal, 88165 $ 14.49 manual screening and rescreening under physician supervision Cytopathology,cervical or vaginal,collected in preservative fluid, 88174 $ 29.31 automated thin layer preparation,screening by automated system, under physician supervision Cytopathology,cervical or vaginal,collected in preservative fluid, 88175 $ 35.65 automated thin layer preparation,screening by automated system and manual rescreening under physician supervision Human Papillomavirus,high-risk types(6) 87624 $ 33.64 No Human Papillomavirus,types 16 and 18 only(6) 87625 $ 33.64 No Follow-Up Colposcopy 57452 $ 105.86 Yes Colposcopy with Biopsy and endocervical curettage 57454 $ 148.78 Yes Colposcopy with Biopsy 57455 $ 138.46 Yes Colposcopy with endocervical curettage 57456 $ 130.57 Yes Surgical Pathology-Level IV 88305 $ 66.46 No 88305TC $ 27.66 No 88305-26 $ 38.80 No N.C.Department of Health and Human Services,Division of public Health, Page 3 Chronic Disease and Injury Section,Cancer Prevention and Control Branch 2/2017 North Carolina Breast and Cervical Cancer Control Program 2017 Services Fee Schedule(1) Physician Visits CPT 2017 Office Visits(7) Code Fee New patient;history,exam,straightforward decision-making; 99201 $ 42.16 10 minutes New patient;expanded history,exam,straightforward decision-making; 99202 $ 72.23 20 minutes New patient;detailed history,exam,straightforward decision-making; 99203 $ 104.35 30 minutes Established patient;evaluation and management,may not require 99211 $ 19.42 presence of physician;5 minutes Established patient;history,exam,straightforward decision-making; 99212 $ 42.00 10 minutes Established patient;expanded history,exam,straighforward decision- 99213 $ 70.73 making; 15 minutes Established patient;detailed history,exam,moderately complex 99214 $ 104.24 decision-making;25 minutes 00400 Anesthesia for procedures on the integumentary system,anterior trunk,not otherwise specified.Medicare Base Units=3 Not to exceed 3 Base Units plus Time Units(length of time spent providing anesthesia service in 15 minute increments) times Conversion Rate($21.45)or$325,whichever is lower. Medicare's methodology for the payment of anesthesia services is outlined in chapter 12 of the Medicare Claims Processing Manual at www.cros.hhs.gov/manuaWdownloads/clml04cl2.ndf.The carrier-specific Medicare anesthesia conversion rates are available at www.cros.hhs.2ov/center/anesth.asD. 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. N.C.Department of Health and Human Services,Division of Public Health, Page 4 Chronic Disease and Injury Section,Cancer Prevention and Control Branch 2/2017 North Carolina Breast and Cervical Cancer Control Program 2017 Services Fee Schedule(1) NOTES: (1) NC BCCCP covers only the physician's fee. Any facility charges associated with these CPT codes are not covered (2) Code 77063 should be listed as a separate code in addition to the code for the screening mammogram code,77057 or (3) Code G0279 should be listed as a separate code in addition to G0204 or G0206 for the primary mammogram. (4) 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 19281-19286. (5) 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. (6) HPV DNA testing is a reimbursable procedure if used for screening in conjunction with Pap testing or for follow-up of an abnormal Pap 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 CDC funds may be used for reimbursement of HPV genotyping. (7) 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 NC BCCCP screening visits. N.C.Department of Health and Human Services,Division of Public Health, Page 5 Chronic Disease and Injury Section,Cancer Prevention and Control Branch 2/2017