HomeMy WebLinkAbout2020-648-E Health-UNC Health Care System mammogram screeningsRevised 6/19
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[Departmental Use Only]
TITLE UNC BCCCP Program
FY 2020-2021
ORANGE COUNTY
UNC BCCCP PROGRAM CONTRACT
NORTH CAROLINA
THIS AGREEMENT, made and entered into this first day of July, 2020, (“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;
W I T N E S S E T H:
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 2020
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, 2020 to June 30, 2021.
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 Five
Thousand Dollars ($5,000) 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.
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
Revised 6/19
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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 11A 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. 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 Non-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.
By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the
services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S.
147-86.81.
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.
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
Revised 6/19
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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: ________________________
200 S. Cameron St. UNC Health Care System
P.O. Box 8181 211 Friday Center Drive
Hillsborough, NC 27278 Chapel Hill, NC 27517
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
System Vice President, Managed Care
Revised 6/19
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ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Department
Party/Vendor Name: UNC Health Care System Party/Vendor Contact Person: Kathryn Grant Contact Phone: 984-
974-1274 Party/Vendor Address: 211 Friday Center Drive City Chapel Hill State: NC Zip: 27517 Department:
Health Amount: $5,000 Purpose: BCCCP Mamogram Screenings Budget Code(s): 10414020-631010-71401 Vendor
# 30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New
Renewal Amendment Effective Date 7/1/20 Approved by Board Yes No Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affir matively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that was
addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Allen Coleman upon completion: acoleman@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
9/14/2020
9/15/2020
9/16/2020
9/16/2020
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, 2020 and June
30, 2021. 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 2020 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 i tself
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 Elizabeth Bullard 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
Elizabeth Bullard
P (984) 215-5888
F (984) 974-9039
Elizabeth.Bullard2@unchealth.unc.edu
Exhibit A
NC Breast and Cervical Cancer Program
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
UNC FP will send invoices to:
Orange County Health Department, BCCCP Program
ATTN: Accounts Payable
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- Integrated Billing
PO Box 168
Chapel Hill, NC 27514
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
2020 Office Fee
Code Fee Allowed
Clinical breast examination N/A Yes
77063 53.35$ No
77063TC 23.49$
77063-26 29.86$
77067 131.10$ No
77067TC 92.91$
77067-26 38.19$
Radiological examination, surgical specimen 76098 41.21$ No
76098TC 25.45$
76098-26 15.76$
Diagnostic mammography, unilateral, includes CAD 77065 128.54$ No
77065TC 87.87$
77065-26 40.67$
Diagnostic mammography, bilateral, includes CAD 77066 161.91$ No
77066TC 112.04$
77066-26 49.87$
G0279 53.35$ No
G0279TC 23.49$
G0279-26 29.86$
Ultrasound, complete examination of breast including axilla,76641 102.96$ No
unilateral (4)76641TC 66.73$
76641-26 36.23$
Ultrasound, limited examination of breast including axilla, 76642 84.37$ No
unilateral (4)76642TC 50.62$
76642-26 33.75$
Surgical evaluation/Consultation N/A (10)Yes
Fine needle aspiration biopsy without imaging guidance, first lesion 10021 95.77$ Yes
Each additional lesion 10004 51.01$ Yes
Fine needle aspiration biopsy including ultrasound guidance, first lesion 10005 126.05$ Yes
Each additional lesion 10006 59.02$ Yes
Puncture aspiration of cyst of breast 19000 105.82$ Yes
Puncture aspiration of cyst of breast, each additional cyst, used with 19000 19001 26.93$ Yes
Breast biopsy, with placement of localization device and imaging of 19081 588.30$ Yes
biopsy specimen, percutaneous; stereotactic guidance; first lesion (5)
Each additional lesion (5) 19082 472.38$ Yes
Breast biopsy, with placement of localization device and imaging of 19083 581.78$ Yes
biopsy specimen, percutaneous; ultrasound guidance; first lesion (5)
Each additional lesion (5)19084 459.57$ Yes
Breast biopsy, percutaneous, needle core, not using imaging guidance 19100 149.01$ Yes
Breast biopsy, open, incisional 19101 326.42$ Yes
North Carolina Breast and Cervical Cancer Control Program
Breast Cancer Screening and Diagnostic Procedures
2020 Services Fee Schedule (1)
For the Period 01/01/2020 through 12/31/2020
Follow-Up
Created: 1/14/2020
Screening mammography, bilateral, includes CAD
Screening
Screening digital breast tomosynthesis, bilateral (2)
Diagnostic digital breast tomosynthesis, unilateral or bilateral (3)
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
2020 Office Fee
Code Fee Allowed
Excision of cyst, fibroadenoma or other benign or malignant tumor, 19120 493.62$ Yes
aberrant breast tissue, duct lesion, nipple or areolar lesion; open;
one or more lesions
Excision of breast lesion identified by preoperative placement of 19125 545.54$ Yes
radiological marker; open; single lesion
Each additional lesion separately identified by a preoperative 19126 160.23$ Yes
radiological marker
Placement of breast localization device, percutaneous; mammographic 19281 237.99$ Yes
guidance; first lesion (6)
Each additional lesion (6)19282 167.10$ Yes
Placement of breast localization device, percutaneous; stereotactic 19283 263.65$ Yes
guidance; first lesion (6)
Each additional lesion (6)19284 199.80$ Yes
Placement of breast localization device, percutaneous; ultrasound 19285 438.95$ Yes
guidance; first lesion (6)
Each additional lesion (6)19286 373.47$ Yes
Ultrasonic guidance for needle placement, imaging 76942 55.82$ No
supervision and interpretation 76942-TC 24.10$
76942-26 31.71$
Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic 88172 54.65$ No
study to determine adequacy of specimen(s), first evaluation episode 88172TC 18.06$
88172-26 36.59$
Cytopathology, evaluation of fine need aspirate; immediate cytohistologic 88177 29.19$ No
study to determine adequacy of specimen(s), each separate additional 88177TC 6.71$
evaluation episode 88177-26 22.48$
Cytopathology, evaluation of fine needle aspirate; interpretation and report 88173 149.54$ No
88173TC 77.41$
88173-26 72.13$
Surgical pathology, gross and microscopic examination 88305 68.23$ No
88305TC 29.81$
88305-26 38.42$
Surgical pathology, gross and microscopic examination; requiring microscopic 88307 265.44$ No
evaluation of surgical margins 88307TC 181.05$
88307-26 84.38$
Morphometric analysis, tumor immunohistochemistry, per specimen; manual 88360 120.50$
88360TC 77.47$
88360-26 43.03$
Morphometric analysis, tumor immunohistochemistry, per specimen; 88361 122.43$
using computer-assisted technology 88361TC 76.80$
88361-26 45.63$
00400 21.63$
Moderate (concious) sedation (10-22 minutes for individuals 5 yr. or older) (8)99156 77.74$
Each additional 15 minutes (8)99157 63.35$
Anesthesia for procedures on the integumentary system, anterior trunk, not
otherwise specified (7)
Breast Cancer Screening and Diagnostic Procedures
2020 Services Fee Schedule (1)
North Carolina Breast and Cervical Cancer Control Program
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
2020 Office Fee
Code Fee Allowed
Pelvic examination - Bimanual N/A Yes
Cytopathology, cervical or vaginal, any reporting system, requiring 88141 25.10$
Cytopathology (liquid-based Pap test) cervical or vaginal, collected 88142 20.26$
in preservative fluid, automated thin layer preparation; manual
screening under physician supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,88143 23.04$
automated thin layer preparation; manual screening and rescreening
under physician supervision
Cytopathology (conventional Pap test), slides cervical or vaginal 88164 15.12$
reported in Bethesda System, manual screening under physician
supervision
Cytopathology (conventional Pap test), slides cervical or vaginal 88165 42.22$
reported in Bethesda System, manual screening and rescreening under
physician supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,88174 25.37$
automated thin layer preparation; screening by automated system,
under physician supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,88175 26.61$
automated thin layer preparation; screening by automated system and
manual rescreening, under physician supervision
Human Papillomavirus, high-risk types (9)87624 35.09$ No
Human Papillomavirus, types 16 and 18 only (9)87625 40.55$ No
Colposcopy of the cervix 57452 118.08$ Yes
Colposcopy of the cervix, with biopsy and endocervical curettage 57454 161.66$ Yes
Colposcopy of the cervix, with biopsy 57455 152.11$ Yes
Colposcopy of the cervix, with endocervical curettage 57456 142.88$ Yes
Surgical pathology, gross and microscopic examination 88305 68.23$ No
88305TC 29.81$ No
88305-26 38.42$ No
Surgical pathology, gross and microscopic examination; requiring 88307 265.44$ No
microscopic evaluation of surgical margins 88307TC 181.05$ No
88307-26 84.38$ No
North Carolina Breast and Cervical Cancer Control Program
2020 Services Fee Schedule (1)
Cervical Cancer Screening and Diagnostic Procedures
Screening
interpretation by physician
Follow-Up
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
CPT 2020
Code Fee
New patient; history, exam, straightforward decision-making; 99201 44.20$
10 minutes
New patient; expanded history, exam, straightforward decision-making; 99202 73.61$
20 minutes
New patient; detailed history, exam, straightforward decision-making; 99203 104.47$
30 minutes
Established patient; evaluation and management, may not require 99211 22.21$
presence of physician; 5 minutes
Established patient; history, exam, straightforward decision-making; 99212 43.86$
10 minutes
Established patient; expanded history, exam, straighforward decision-99213 72.77$
making; 15 minutes
Established patient; detailed history, exam, moderately complex 99214 105.81$
decision-making; 25 minutes
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.
(1)NC BCCCP covers only the physician's fee. Any facility charges associated with these CPT codes are not covered.
(2)
(3)
(4)Bilateral ultrasound may be reimbursed at one and one-half times the unilateral rate (not double unilateral rate).
(5)
(6)
(7)
(8)Example: If procedure is 50 minutes, code 99156 + (99157 x 2). No separate charge allowed if procedure <10 minutes.
(9)
(10)
Not to exceed 3 base units plus time units (length of time spent providing anesthesia service in 15-minute increments) times
conversion rate ($21.63) 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:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
The carrier-specific Medicare anesthesia conversion rates are available at:
https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center
List separately in addition to code for primary procedure 77067.
List separately in addition to 77065 or 77066.
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 typically not
appropriate for NC BCCCP screening visits, but may be used when provider spends extra time to do a detailed risk assessment.
BCCCP may pay for up to two surgical consultations.
HPV DNA testing is not a reimbursable procedure if used as an adjunctive screening test to the Pap for women under 30 years of a
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.
Codes 19081-19084 are to be used for breast biopsies that include image guidance, placement of localization device, and
imaging of specimen. They should not be used in conjunction with 19281-19286.
Global and Split Fees
Both global and split fees apply to the breast and cervical procedures listed on this fee schedule. The method and direction of payment will
NOTES:
Physician Visits
Office Visits (10)
North Carolina Breast and Cervical Cancer Control Program
2020 Services Fee Schedule (1)
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177
CERTIFICATE OF COVERAGE
Certificate Holder: To Whom It May Concern
Insurer: State of North Carolina
Authorization: Public Officers & Employee Liability Insurance Commission of
North Carolina and the General Statutes of North Carolina, Chapter
143, Articles 31 to 31D, Sections §143-291 to §143-300.
Period: October 1, 2019 until October 1, 2020
Coverage: A) Tort Claims against Departments, Agencies, and Employees
B) Excess Liability for State Employees
BRIT Global Specialty USA - Policy # PK1035818
C) Workers’ Compensation
Limits A) $1,000,000 for Tort claims against the State
B) $2,000,000 per employee/$10,000,000 aggregate for claims
against state employees
C) Statutory Limits for Workers’ Compensation
Description: The University of North Carolina at 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:
Margie Boyd
Risk Manager
UNCCH 2019-2020
DocuSign Envelope ID: FB8633A7-7427-4234-85C2-8B1508ED7177