HomeMy WebLinkAbout20240428.tiffRESOLUTION
RE: APPROVE AMENDMENT #6 TO DIAGNOSTIC SERVICES AGREEMENT FOR
WOMEN'S WELLNESS CONNECTION PROGRAM AND AUTHORIZE CHAIR TO
SIGN - BANNER IMAGING SERVICES COLORADO, LLC
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with Amendment #6 to the Diagnostic Services
Agreement for the Women's Wellness Connection Program between the County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of
the Department of Public Health and Environment, and Banner Imaging Services Colorado, LLC,
commencing July 21, 2024, and ending July 20, 2027, with further terms and conditions being as
stated in said amendment, and
WHEREAS, after review, the Board deems it advisable to approve said amendment, a
copy of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that Amendment #6 to the Diagnostic Services Agreement for the Women's
Wellness Connection Program between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Public Health
and Environment, and Banner Imaging Services Colorado, LLC, be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said amendment.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 21st day of February, A.D., 2024.
BOARD OF COUNTY COMMISSIONERS
WELD COU O
ATTEST: _.)��
Weld County Clerk to the Board
. I,c %61 -
APP
Deputy Clerk to the Board
FORM:
ounty Attorney
IDate of signature: z'7 / Z -
Ross, Chair
Perry L. ck, Pro-Tem
EXCUSED
Mike Freeman
ScottK. James
ne
CC: H'L 0c/5M f6F)
O g/og/, q
2024-0428
HL0057
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BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS -AROUND TITLE: Banner Imaging Services 6'" Amendment for WWC Diagnostic Imaging/Radiology
DEPARTMENT: PUBLIC HEALTH AND ENVIRONEMNT DATE: January 19, 2024
PERSON REQUESTING: Jason Chessher, Executive Director
Shaun May, Public Health Services Director
Brief description of the problem/issue:
For the Board's review and approval is a contract renewal between Banner Imaging Services Colorado, LLC
and the Board of County Commissioners of Weld County for the use and benefit of the Weld County
Department of Public Health and Environment (WCDPHE).
The Health Department requests approval of this 6'h amendment of our contract with Banner Imaging Services
Colorado, LLC to provide the diagnostic imaging/radiology services (mammograms, ultrasounds, and MRIs) to
eligible Women's Wellness Connection (WWC) patients referred to Banner Imaging Services by the Health
Department.
This 6'h amendment will extend this agreement till July 20, 2027. Activities will be conducted by current staff; no
additional FTE is being requested.
What options exist for the Board?
Consequences: If the Board declines to approve this agreement, the WCDPHE will not be able to
provide optimal care for our patients. This will result in greater challenges for us to assist qualified
patients at increased risk of breast and cervical cancer in connecting with diagnostic and radiology
services.
Impacts: With approval of the Board, the WCDPHE will be able to connect our qualified WWC patients
with Banner Imaging resulting in improved health outcomes and increased customer service.
Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years): This is a no -cost agreement
with Banner Imaging. The cost of the services provided by Banner Imaging will be invoiced and paid by
WCDPHE. The Colorado Department of Public Health and Environment (CDPHE) Women's Wellness
Connection program will reimburse the WCDPHE. A list of the surgical services to be provided and their
associated cost is listed in Appendix A.
Recommendation: I recommend approval of this agreement with Banner Imaging for WWC patients.
Support Recommendation Schedule
Place on BOCC Agenda Work Session Other/Comments:
Perry L. Buck, Pro-Tem
Mike Freeman
Scott K. James
Kevin D. Ross , Chair
Lori Saine
#4
2/Z I
2024-0428
01,0031
Cheryl Hoffman
From:
Sent:
To:
Cc:
Subject:
Approve - thanks!
Scott James
Monday, January 22, 2024 8:45 AM
Cheryl Hoffman
Esther Gesick
Re: Banner Imaging WWC
Scott K. James
Weld County Commissioner, District 2
1150 O Street, P.O. Box 758, Greeley, Colorado 80632
970.336.7204 (Office)
970.381.7496 (Cell)
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On Jan 22, 2024, at 8:35 AM, Cheryl Hoffman <choffman@weld.gov> wrote:
Here's the 3rd of 7.
Do you approve of placement on the BOCC agenda after your review?
Cheryl L. Hoffman
Deputy Clerk to the Board
1 150 O Street/P.O. Box 758
Greeley, CO 80632
Tel: (970) 400.4227
choffman@weld.gov
From: Karla Ford <kford@weld.gov>
Sent: Sunday, January 21, 2024 1:35 PM
To: Cheryl Hoffman <choffman@tweld.gov>
Subject: FW: Banner Imaging WWC
Karla Ford X
SIXTH AMENDMENT TO DIAGNOSTIC SERVICES AGREEMENT
(FOR WOMEN'S WELLNESS CONNECTION PROGRAM)
(031403.43839)
THIS SIXTH AMENDMENT TO DIAGNOSTIC SERVICES AGREEMENT (FOR
WOMEN'S WELLNESS CONNECTION PROORAM) (this "Amendment") is made and
entered into as of the signature dates set forth below, to be effective as of July 21, 2024, by
and between BANNER IMAGING SERVICES COLORADO, LLC, a Colorado limited
liability company ("BIS"), and County of Weld, State of Colorado, by and through the Board
of Commissioners of Weld County, on behalf of the Weld County Department of Public
Health and Environment ("WCDPHE"),
WIT NESSETH:
WHEREAS, WCDPHE and Banner Health, an Arizona nonprofit corporation d/b/a
North Colorado Medical Center ("Banner") are parties to that certain Services Agreement
dated July 21, 2014, as amended (together the "Agreement"), pursuant to which Banner will
provide the technical component of the diagnostic imaging/radiology services (the "Services")
as more particularly described therein; and
WHEREAS, Banner wishes to assign all of its right, title and interest under the
Agreement to BIS; and
WHEREAS, BIS is a subsidiary of and solely owned by Banner; and
WHEREAS, in accordance with the terms and conditions hereof, the parties desire to
amend the Agreement to memorialize the assignment of the Agreement and clarify certain
provisions to state that BIS will provide both the professional and technical component ofthe
Services as set forth in the Agreement among other things.
NOW, THEREFORE, for and in consideration of the mutual covenants and promises
contained herein, the receipt and sufficiency of which am hereby acknowledged, it is
understood and agreed upon by the parties hereto as follows:
I. Amendment of Agreement
A. Paragraphs 3,4,5,6 and 7 of the Recitals are hereby deleted and replaced as follows:
WHEREAS, BIS operates certain outpatient clinics providing radiology services (the
Clinics"); and
WHEREAS, MS provides the technical and professional component of diagnostic
imaging/radiology services (the "Services") at the Clinics; and
WHEREAS, WCDPHE desires to engage BIS to provide the technical and professional
components of the diagnostic imaging/radiology services for the Designated Patient(s) of the
Program and BIS desires to be so engaged, in accordance with the terms and conditions set forth
herein.
Section 1.1 of the Agreement is hereby deleted in its entirety and replaced as follows:
1.1 Provision of Services. Cpon presentation of a voucher as set forth on (Schedule
B) attached hereto and incorporated herein by this reference, and if required, an order of an
appropriately licensed provider (employed or otherwise contracted to provide services to
WCDPHE), BIS shall provide the technical and professional component of such diagnostic
imaging/radiology services (the "Services") to the Designated Patient(s) as set forth on
("Schedule A"), at the Medicare Rates and CPT Codes for the Women's Wellness Connection,
attached hereto and incorporated herein by this reference. BIS shall supply all qualified
personnel, materials, and equipment necessary to provide the Services.
C. Section 1.2 ofthe Agreement is hereby deleted in its entirety and replaced as follows:
1.2 Results. BIS shall prepare or cause to be prepared written or electronic reports in
medical terminology with respect to all Services. BIS shall, upon request by a treating provider
at WCDPHE., provide test results and formal recommendations to WCDPHE within seven (7)
days after test completion. Otherwise, Banner shall provide WCDPHE with that amount of
information concerning the program participant ass necessary for WCDPHE to make payment
for the Services provided.
D. Section 3 (Term and Termination) of the Agreement is hereby amended to extend the term of
the Agreement for an additional three (3) year period as of the Effective Date and continuing
through July 20, 2027, subject to earlier termination as provided in Section 3 of the Agreement.
E. Section 4.1 of the Agreement is hereby deleted in its entirety and replaced as follows:
4.1 Compensation. WCDPHE agrees to compensate BIS for the Technical Services
at the rate of one hundred percent (l00%) of the allowable payment for each type of
diagnostic/imaging radiology service provided to a Designated Patients, based upon Schedule
A Medicare Rates and CPT Codes for the Women's Wellness Connection, in effect at the time
the Services are performed.
4.1.1 FundsAvailability. Financial obligations of WCDPHE payable afterthe
current fiscal year are contingent upon funds for that purpose being appropriated, budgeted, and
otherwise made available. Execution of this Agreement by WCDPHE does not create an
obligation on the part of WCDPNE to expend funds not otherwise appropriated in each
succeeding year.
F. Section 4.2 null's Agreement is hereby deleted in its entirety and replaced as follows:
4.2 (j in . BIS shall submit invoices monthly to WCDPHE for Services provided to
Designated Patient(s). WCDPHE shall pay such invoices within thirty (30) days following the
month in which the Services were rendered. BIS agrees that BIS shall not, under any
circumstances, bill any Designated Patient(s) or third -party payer for the Services provided
pursuant to this Agreement.
Section 6 of the Agreement is hereby deleted in its entirety and replaced as follows:
6. Mutual Indemnification. As permitted under Colorado law, each party shall indemnify
and save harmless the other party for, from and against all actions, liabilities, losses, damages,
claims and demands whatsoever, including costs, expenses and attorneys' fees, resulting, or
claimed to have resulted solely from any intentional or negligent acts or omissions of the
indemnifying party or its employees, subcontractors or agents engaged in the work under this
Agreement at the time of the event or occurrence upon which such actions, claims or demands
are based.
G. Section 19 o f the Agreement shall be updated so that notices will be provided to BIS and Banner
Health at the following address:
Banner Imaging Services Colorado, LLC
2901 N. Central Ave., Suite 160
Phoenix, AZ 85012
Attn: BIS CEO
With a copy to: Banner Health
2901 N. Central Ave., Suite 160
Phoenix, AZ 85012
Attn: General Counsel
2. Assieoment. BIS hereby accepts the forgoing assignment and assumes all obligations ofthe
Banner under the Agreement arising from and after the Effective Date. All of the terms
covenants and conditions set forth herein shall be binding upon Banner and its successors and
assigns and inure to the benefit of the BIS and its successors and assigns.
3. Accentance of Assienment Banner joins in this Amendment to consent to this assignment
form and after the Effective Date.
4. Agreement Effective. Except as otherwise expressly provided herein, MI terms and conditions of
the Agreement shall remain unmodified and in full force and effect, including previously
executed amendments to the original agreement.
5. Precedence of Amendment. In the event of a conflict between the terms and conditions of this
Amendment and the terms and conditions of the Agreement, the terms and conditions ofthis
Amendment shall govern and control.
6. Capitalized Terms. All capitalized terms used in this Amendment and not otherwise defined
herein shall have the meaning ascribed to such terms in the Agreement.
7. Incorporation. This Amendment shall be attached to, and made a part of, the Agreement.
8. Counterparts. This Amendment may be executed in one or more copies or counterparts, each of
which when signed shall be an original, but all of which together shall constitute one
instrument.
[Signature Page to Follow.)
DocuSign Envelope ID: 074CE887-8F84-4A72-A4F8-2DBB66BFCA6C
IN WITNESS WHEREOF, the parties hereto have executed this Amendment,
or by signature oftheirduy authorized representative, as ofthe signature dates set
forth below, to be effective as ofthe Effective Date.
BANNER IMAGING SERVICES COLORADO, LLC:
Name: 'i'°
Title: VP Ambulatory Services
Date: April 22, 2024 I 8:26 PM MST
ATTEST:
BY:
DATE:
ASSIGNMENT ACCEPTED AND AGREED TO:
BANNER HEALTH
Name: ,�tiM lot`
Title: VP Ambulatory Services
Date: April 22, 2024 I 8:26 PM MST
4
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY OLOFtADO
Bela D. Ross, Chair
FED 2 2024
ooa 1 a4ia8`
Schedule A
Medicare
Rates
and CPT
Codes
- Updated
June
2023
(updates
in
Bold)
Cancer Prevention
and
Early
Detecton
Program/Women's Wellness
Connection Clinical
Services
Reimbursable
Services and
Procedures
for June
30, 2023
to June
29, 2024
Listed below are allowable
Connection (WWC)
https://www.cros.gov/medicare/physician-fee-schedule/search/overview.
procedures
Clinical Services
and the corresponding
program. These
rates are
CPT codes
based on information
for use in the
Rates are incorporated
covered
related to
contact
through
Cancer
found on
WWC
cancer screening
your CDPHE
Prevention
the
Centers
into the
Clinical
Organizational
and
for
program's
Services
and diagnostics
Early
Medicare
Bundled
Detection
and
of
Lead
and
to
the
for
Payment
Medicaid
aid
breast
approval
(CPED)/Women's
Wellness
website,
System (BPS) at
in negotiating subcontracts.
and cervix may be
of any codes not
the
eligible
on this
beginning of
Reimbursement
for reimbursement
list.
each
fiscal
for
through
year. Codes
treatment services
the CPED/W
are
is
provided
not allowed.
WC Clinical
to
show what
Additional
Services
services are
CPT codes
program. Please
CPT CODES
OFFICE VISITS
End
Notes
2023 CO
Rates
2023 Prof
(2 6)
2023 Tech
(TC)
99202
New patient; expanded history, exam, straightforward decision -making; 15-29 minutes
$74.40
99203
New Patient; detailed history, exam, straightforward decision -making;
30-44
minutes
$114.59
99204
New Patient; comprehensive history, exam, moderate complexity decision -making; 45-59 minutes
I
$169.84
99205
New patient; comprehensive history, exam, high
complexity decision -making; 60-74 minutes
1
$224.00
99211
Established patient; evaluation and management, may not require presence of physician; presenting
problems are minimal
$24.19
99212
Established patient; history. exam, straightforward decision -making; 10-19 minutes
$58.20
99213
Established Patient; expanded history, exam, straightforward decision -making; 20-29 minutes
$92.52
99214
Established
Patient; detailed history, exam, moderately complex decision -making; 30-39 minutes
$130.73
99385
Initial comprehensive preventive medicine evaluation and management; history, examination,
counseling and guidance, risk factor reduction, ordering of appropriate immunizations and
procedures; 18 to 39 years of age
lab
2
intentionally
left blank
99386
Same as 99385, but 40 to 64 years of age
2
intentionally
left blank
99387
Same as 99385, but 65 years of age or older
2
intentionally
left blank
99395
Periodic
counseling
procedures;
comprehensive preventive
and guidance, risk
18 to 39 years of
medicine evaluation and management; history, examination,
factor reduction, ordering of appropriate immunizations and lab
age
2
intentionally
left blank
99396
Same as 99395 but 40 to 64
years of age
2
left
intentionally
blank
99397
Same as 99395, but 65 years of age or older
2
intentionally
left blank
CPT CODES
BREAST SCREENING AND DIAGNOSTIC
SERVICES
\otes
End
2023 (1)
Rates
2023 Prof
(26)
2023 Tech
(TC)
76098
Radiological examination, surgical specimen
544
A
lo
$15.37
$28.74
76641
Ultrasound, complete examination of breast including axilla, unilateral
$109.12
$35.55
$73.57
76642
Ultrasound, limited examination of breast including axilla, unilateral
3
$89 62
$33 13
$56 49
76942
Ultrasonic guidance for needle placement, imaging supervision and interpretation
3
$60 46
$30 66
$29 80
19000
Puncture aspiration of cyst of breast
$106 66
19001
Puncture aspiration of cyst of breast, each additional cyst, used with 19000
$26 77
.,
19100
Breast biopsy, percutaneous, needle core, not using imaging guidance
$157 03
'' -
_ ! --' `,:
19101
Excision Procedures on the Breast
$341 80
19120
Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion,
nipple or areolar lesion, open, one or more lesions
$534 05
`
19125
Excision of breast lesion identified by preoperative placement of radiological marker, open, single
lesion
$587 57
,
'
19126
Excision of breast lesion identified by preoperative placement of radiological marker, open, each
additional lesion separately identified by a preoperative radiological marker
$158 37
; ri 4` = 'ri"
" e
,
19081
Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous,
stereotactic guidance, first lesion
7
$532 20
,
r ,, {„
i `{ ; A_
19082
Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous,
stereotactic guidance, each additional lesion
7
$414 74
_
„
19083
Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous,
ultrasound guidance, first lesion
7
$532 74
19084
Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous,
ultrasound guidance, each additional lesion
7
$408 93
19085
Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous,
magnetic resonance guidance, first lesion
7
$821 20
-
-
19086
Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous,
magnetic resonance guidance, each additional lesion
7
$640 86
-
`'
19281
Placement of breast localization device, percutaneous, mammographic guidance, first lesion
8
$253 73
19282
Placement of breast localization device, percutaneous, mammographic guidance, each additional
lesion
8
$181 22
' '" _ -
19283
Placement of breast localization device, percutaneous, stereotactic guidance, first lesion
8
$274 20
1 `
".^„;' „Y ,,
19284
Placement of breast localization device, percutaneous, stereotactic guidance, each additional lesion
8
$203 19
«'
19285
Placement of breast localization device, percutaneous, ultrasound guidance, first lesion
8
$395 45
;
19286
Placement of breast localization device, percutaneous, ultrasound guidance, each additional lesion
8
$325 91
r ,_`
19287
Placement of breast localization device, percutaneous, magnetic resonance guidance, first lesion
8
$683 08
rs ,
`t
19288
Placement of breast localization device, percutaneous, magnetic resonance guidance, each additional
lesion
8
$530 47
^^
{"i
,',"
10021
Fine needle aspiration without imaging guidance, first lesion
$105 75
10004
Fme needle aspiration biopsy without imaging guidance, each additional lesion
$51 92
' ,,
10005
Fme needle aspiration biopsy including ultrasound guidance, first lesion
$141 13
10006
Fine needle aspiration biopsy mcludmg ultrasound guidance, each additional lesion
$61 31
_ ` , w
' Yr
10007
Fme needle aspiration biopsy including fluoroscopic guidance, first lesion
$312 29
- -.:'S,.',
y`
10008
Fme needle aspiration biopsy mcludmg fluoroscopic guidance, each additional lesion
$150 10
,„:
10009
Fine needle aspiration biopsy mcludmg CT guidance, first lesion
$459 72
10010
Fine needle aspiration biopsy including CT guidance, each additional lesion
$250 62
4 t
y y i�,
10011
Fine needle aspiration biopsy mcludmg MRI guidance, first lesion
9
(see end note)
,
10012
Fme needle aspiration biopsy including MRI guidance, each additional lesion
9
(see end note)
v. N
88172
Cytopathology, evaluation of tine needle aspirate, immediate cytohistologic study to determine
adequacy of specimen(s), first evaluation episode
$57 49
$35 51
$21 98
88177
Cytopathology, evaluation of fine needle aspirate, immediate cytohtstologtc study to determine
adequacy of specimen(s), each separate additional evaluation episode
$30 23
$21 69
$8 54
88173
Cytopathology, evaluation of fine needle aspirate, interpretation and report
$168 51
$69 94
$98 57
88305
Surgical pathology, gross and microscopic examination
$74 12
$37 20
$36 92
88307
Surgical pathology, gross and microscopic examination, requiring microscopic evaluation of surgical
margins
$304 31
$82 27
$222 04
400
Anesthesia for procedures on the integumentary system, antenor trunk, not otherwise specified
Medicare Base Units = 3
14
(see end note)
-
,�Y
%'`
- ` ' -
A'
77053
Mammary ductogram or galactogram, single duct
$56 12
$17 43
$38 70
77046
Magnetic resonance imaging (MRI), breast, without contrast, unilateral REQUIRES WWC
PREAPPROVAL
6
$232 92
$69 78
$163 15
77047
Magnetic resonance imaging (MRI), breast, without contrast, bilateral REQUIRES WWC
PREAPPROVAL
6
$241 15
$77 29
$163 86
77048
Magnetic resonance imaging (MRI), breast, mcludmg CAD, with and without contrast, unilateral
REQUIRES WWC PREAPPROVAL
6
$370 54
$101 53
$269 01
77049
Magnetic resonance imaging (MRI), breast, mcludmg CAD, with and without contrast, bilateral
REQUIRES WWC PREAPPROVAL
6
$377 98
$111 10
$266 88
77063
Screening digital breast tomosynthests, bilateral (3D mammography)
4
$54 96
$29 34
$25 62
77065
Diagnostic Mammography, unilateral, includes CAD
$132 12
$38 99
$93 14
77066
Diagnostic Mammography, bilateral, includes CAD
$166 70
$47 95
$118 76
77067
Screening Mammography, bilateral
$135 40
$36 93
$98 48
G0279
Diagnostic digital breast tomosynthests, unilateral or bilateral (diagnostic 3D mammography)
5
$54 96
$29 34
$25 62
Various
To include any pre -operative testing procedures medically necessary for the planned surgical
procedure (e g , complete blood count, urinalysis, pregnancy test, pre -operative CXR, etc )
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i. '�,, , r'� vtill ,�., n�� T I'�a 411 511 r'' a
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I C.�G ry �..,.�- fyi � T.14, +I Pa LlF�}��j�`yN rt"1'1T ,',, L�' -r ,,$� M ft44 1, i. P
.`E+r � II�'�k'-y�r� ;�,, ��I� '�I� C �', , �u�t,�i it,',,
R- I L3nil�Idl r '.F f � � '3 _'�'airb ��111" 1 1 �n W�J'lnl+�f �1f��.s�T..��� �y 1 � f �,+. �
dT!lT�r'L. F Y„= � �,�- I"YM��1't/UI �
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1 ° �',�r�
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, , ,,, ,oIL O
l+�^et�V v��h ��T"� ll
_ ^9r ,t—�
I �`
ka� nor Fs.�
� �,�:1 i`�1 i
51 i�� 'l
r/ GAIT �y��1
ili X i'
e'4 ✓�II �..U�w��'"r'�
�n�l M� �
l,�Fil'�u i
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�.�IaAII '�f l k R,
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�k,-,4111,i,,,,
�'"r��'0r4��
88164
Cytopathology (conventional Pap ER), slides cervical or vaginal reported in Bethesda System,
manual screening under physician supervision
$17 31
,
i
88165
Cytopathology (conventional Pap test), slides cervical or vaginal reported m Bethesda System,
manual screening and rescreening under physician supervision
$42 22
,i,
q ,
T 4
88141
Cytopathology (conventional Pap test), cervical or vaginal, any reporting system, requiring
interpretation by physician
$23 71
88142
Cytopathology (liquid -based Pap test) cervical or vaginal, collected m preservative fluid, automated
thin layer preparation, manual screening under physician supervision
$20 26
_
s
88143
Cytopathology, cervical or vaginal, collected m preservative fluid, automated thin layer preparation,
manual screening and rescreening under physician supervision
$23 04
'
'
88174
Cytopathology, cervical or vaginal, collected m preservative fluid, automated thin layer preparation,
screening by automated system, under physician supervision
$25 37
,
88175
Cytopathology, cervical or vaginal, collected m preservative fluid, automated thin layer preparation,
screening by automated system and manual rescreening, under physician supervision
$26 61
U _
U ,
87624
Human Papillomavirus (HPV) high-nsk types
10
$35 09
` St
87625
Human Papillomavirus, types 16 and 18 only
10
$40 55
57452
Colposcopy of the cervix
$131 49
57454
Colposcopy of the cervix, with biopsy and endocervica1 curettage
$174 03
57455
Colposcopy of the cervix, with biopsy
$166 88
S
57456
Colposcopy of the cervix, with endocervica1 curettage
$157 57
57460
Colposcopy with loop electrode biopsy(s) of the cervix Requires WWC Preapproval Unless Done
After HSIL or AIS Pap test
$330 48
'
57461
Colposcopy with loop electrode Ionization of the cervix Requires WWC Preapproval unless done
after HSIL or AIS Pap test
$367 49
,
U
,
57500
Cervical biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate
procedure) Use this code for cervical polyp removal
$162 00
57505
Endocervical curettage (not done as part of a dilation and curettage)
$163 43
U
57520
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or
without repair, cold knife or laser
11
$367 29
'
57522
Loop electrode excision procedure
11
$314 92
U '
58100
Endometnal sampling (biopsy) with or without endocervical sampling (biopsy), without cervical
dilation, any method (separate procedure) Only for diagnostic purposes following AGC Pap
$105 41
U ,
,,U
`5 ,1 4
"
58110
Endometnal sampling (biopsy) performed m conjunction with Colposcopy (List separately in addition
to code for primary procedure) Only for diagnostic purposes following AGC Pap
$50 81
,
88305
Surgical pathology, gross and microscopic examination
$74 12
$37 20
$36 92
88331
Pathology consultation during surgery, first tissue block, with frozen section(s), single specimen
$105 74
$62 06
$43 68
88332
Pathology consultation during surgery, each additional tissue block, with frozen section(s)
$56 93
$30 68
$26 25
88341
Immunohistochemistry antibody slide
$90 51
$28 24
$62 27
88342
Immunohistochemistry antibody slide
$104 79
$34 78
$70 01
88360
Morphometnc analysis, tumor immunohistochemistry, pre specimen, manual
$123 78
$41 67
$82 11
88361
Morphometric analysis, tumor immunohistochemistry, pre specimen, using computer -assisted
technology
$123 63
$43 65
$79 97
99070
Supplies and materials (except spectacles), provided by the physician over and above those usually
included with the office visit or other services rendered (list drugs, trays, supplies, or materials
provided)
Various
Pre -operative testing; CBC, urinalysis, pregnancy test, etc. These procedures should be medically
necessary for the planned surgical procedure
_
-
- .. _
.
1.1m1
Notes
2023 ( O
Rates
2_1)23 Prot
( 2(►)
21)23 1 e h
( I ( )
400
Anesthesia for procedures on the integumentary system, anterior trunk, not otherwise specified
99156
10-22 minutes for individuals 5 years or older
$75 hi
99157
For each additional 15 minutes
12
$62.27
End
Notes
2023.CO
Rates
2023 Prof
(26)
2023 Tech
(II')
T OorS
I' vruaLOGY FOR BOTH BREAST AND C.
a, en -- a a
;
A 1(AI., ( A .' '. ENIN(y .\ND)
c i
•
87-126
COVID-19 infectious agent detection by nuclei acid DNA or RNA; amplified probe technique
IS
$35.33
87635
COV I ID -19 infectious agent antigen detection by immunoassay technique;
semiquantitative
qualitative
or
IS
$51.31
i
88365
In situ hybridization (eg,FISH), per specimen; initial single
probe stain procedure
$189.83
543 . 05
$146.78
88364
In situ hybridization (eg,FISH), per specimen; each additional single probe stain procedure
$143.58
$34.07
$108.51
88 366
In situ hybridization (eg,FISH), per specimen; each multiplex
probe stain procedure
$293.45
$61.98
$231.46
88307
Morphometric
stain procedure
analysis, in situ hybridization,
computer -assisted, per specimen, initial single probe
$119.34
$33.32
$86.02
88373
Morphometric analysis, in situ hybridization, computer -assisted, per specimen, each additional probe
stain procedure
$71.70
$25.09
$46.66
88374
Morphometric analysis, in situ hybridization, computer -assisted, per specimen, each multiplex stain
procedure
$320.07
$42.62
$277 45
88368
Morphometric
procedure
analysis, in situ hybridization, manual, per specimen, initial single probe stain
.
$149.27
541.63
$107 64
88369
Morphometric analysis, in situ hybridization, manual, per specimen, each additional
procedure
probe stain
$128.28
$33.01
S95 27
88377
Morphometric analysis, in situ hybridization,
manual, per specimen, each multiplex stain procedure
$417 83
$63.61
$354.22
Various
Pre -operative testing;
necessary for the
CBC, urinalysis, pregnancy test, etc. These
planned surgical procedure.
procedures should
be medically
. ,, - _
�
- -
(pr CODES 1
� C�:� i
1.
, ; ` �-
\ilk
Treatment of breast carcinoma in situ, breast cancer, cervical intraepithelial
cancer.
neoplasia and cervical
77061,
77062
Breast tomosynthesis, as screening, diagnostic, unilateral/bilateral.
approved for coverage by CPED/WWC.
These procedures have not been
13
87623
1 I uman Papillomavirus, low
-risk types
END NOTES FOR WWC C'LINIC4L SERVICES
1
All consultations should be billed through the standard "new patient" office visit CPT codes 99202-99205 Consultations billed as 99204 or 99205 must meet
the criteria for these codes These codes (99204-99205) are typically not appropriate for CPED/WWC screening visits However, they may be used when
provider spends extra time A do a detailed risk assessment
2
The 9938X codes shall be reimbursed at or below the 99203 rate, and 9939X codes shall be reimbursed at or below the 99213 rate The type and duration of
office visits should be appropriate to the level of care needed to accomplish screening and diagnostic follow-up within the CPED/WWC While some
programs may need to use 993XX-series codes, Preventive Medicine Evaluation visits are not covered by Medicare and not appropriate for the CPED/WWC
3
Fora bilateral breast ultrasound, a modifier 50 maybe added to either 76641 or 76642 to indicate a bilateral procedure The Medicare Physician Fee Schedule
assigns a "1" bilateral indicator to both CPT codes 76641 and 76642 which means that Medicare will allow 150 percent of the standard reimbursement rate
4
List separately m addition to code for primary procedure 77067
5
List separately m addition to 77065 or 77067
6
Breast MRI can be reimbursed by the in conjunction with a mammogram when a client has a BRCA gene mutation, a first -degree relative who is a BRCA
carrier, or a lifetime risk of 20% or greater as defined by risk assessment models such as BRCAPRO that depend largely on family history Breast MRI also
can be used to assess areas of concern on a mammogram, or to evaluate a client with a history of breast cancer after completing treatment Breast MRI should
never be done alone as a breast cancer screening tool Breast MRI cannot be reimbursed to assess the extent of disease in a women who has just been newly
diagnosed with breast cancer in order to determine treatment
7
Codes 19081-19086 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 19281-19288
8
Codes 19281-19288 are for image guidance placement of localization device without image -guided biopsy These codes should not be used in conjunction
with 19081-19086
9
For CPT 10011 use the reimbursement rate for CPT code 10009 For CPT 10012 use the reimbursement rate for CPT code 10010
10
HPV DNA testing is not a reimbursable test for women under 30 years of age
11
A LEEP or comzation of the cervix, as a diagnostic procedure, may be reimbursed based on ASCCP recommendations Pre -approval of this procedure for
reimbursement is required A LEEP or comzation of the cervix as a treatment procedure cannot be reimbursed by CDPHE
12
Example If procedure is 50 minutes, code 99156 + (99157 x 2) No separate charge allowed if procedure
<10 minutes
13
These procedures have not been approved for coverage by Medicare Please see code 77063 as the approved code for screening digital breast tomosynthesis,
bilateral 3D mammography
14
The carrier specific Medicare anesthesia conversion rates are available here https //www cros gov/Center/Provider-Type/Anesthesiologists-Center html
Medicare's methodology for the payment of anesthesia services are outlined in the Medicare Claims Processing Manual, Chapter 12, pages 99-107, available
here http //www sins hhs gov/manuals/downloads/c1m104c12 pdf
15
States have received federal funding and test kits for free COVD-19 testing These were specifically provided so that uninsured people could get free testing
Since WWC/CPED is payor of last resort, this should be the first resource for any COVID-19 testing required by a provider prior to any procedure When
testing cannot be covered by those resources for reasons such as the free testing only be administered to people who are symptomatic, then WWC/CPED can
cover the required COVID-19 antigen testing If your organization pays for COVID testing, your organization should be able to track all tests results and link
them to an actual screening or diagnostic procedure if the COVID-19 test is negative If the COVID-19 test is positive, your organization will need to have a
plan for following up to make sure the required procedure gets done at a later date
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 North 17th Avenue, Greeley, CO 80631 www.weldhealth.org
Radiology Service Voucher
This voucher is for the following patient who has been confirmed as eligible for:
Este cupon es para las personas que son conftrmadas elegible para:
o Women's Wellness Connection Program o TB Program
Patient: Please present this voucher, as well as any other paperwork given to you, as you arrive for your
radiology appointment to ensure proper billing. Your appointment is scheduled at:
Al llegar a su cita por favor presente este cupon y otros documentos necesarios entregados a usted, para asegurar la
facturacidn apropiada. Su cita es programada en:
o Summit View Medical Commons
2001 70th Avenue, Greeley, CO 80634
(970) 810-6070
o North Colorado Medical Center
1801 16th Street, Greeley, CO 80631
(970) 810-4121
Appointment date/time: Patient's Date of Birth:
Fecha de la cita Fecha de nacimiento
Patient's name:
Nombre del paciente
Covered service for this visit:
Servicio cubierto para esta cita
°All other services will require prior authorization.
Todos otros servicios se requieren autorizacidn previa.
NOTE: This voucher expires 60 days after date of issue.
Issue date: Authorized Signature:
Service Provider: please bill Weld County as an insurance for the above listed service only:
Weld County Department of Public Health
Attn: Contract Billing
1555 North 17th Avenue, Greeley, CO 80631
If you have any questions or need to reschedule, please call (970) 304-6420.
Si usted tiene alguna pregunta o tiene que cancelar la cita, por favor llame (970) 304-6420.
Health Administration Public Health 8
Vital Records Clinical Services
Tele: 970-304-6410 Tele: 970-304-6420
Fax: 970-304-6412 Fax: 970-304-6416
Environmental Health Communkafion, Emergency Preparedness
Services Education 8 Planning g Response
Tele: 970-304.6415 Tele: 970-304-6470 Teie:9,30,6470
Fax: 970-304-6411 Fax: 970-304-6452 Fax: 970-304-6452
Public Health
Revised 11/2016
Contract F
Entity Information
Entity Name* Entity ID*
BANNER IMAGING SERVICES @00043542
COLORADO LLC
Q New Entity?
Contract Name* Contract ID
BANNER IMAGING SERVICES 6TH AMENDMENT FOR 7781
WWC DIAGNOSTIC IMAGING
Contract Status
CTB REVIEW
Contract Lead *
BFRITZ
Contract Lead Email
bfritz@weld.gov;Health-
Contracts@weld.gov
Contract Description *
BANNER IMAGING SERVICES 6TH AMENDMENT FOR WWC DIAGNOSTIC IMAGING
Contract Description 2
Contract Type* Department
AGREEMENT HEALTH
Amount*
$1.00
Renewable*
NO
Automatic Renewal
Grant
IGA
Department Email
CM-Health@weldgov.com
Department Head Email
CM-Health-
DeptHead@weldgov.com
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY@WEL
DGOV.COM
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
Parent Contract ID
Requires Board Approval
YES
Department Project #
Requested BOCC Agenda Due Date
Date* 01 /25/2024
01/29/2024
Will a work session with BOCC be required?*
NO
Does Contract require Purchasing Dept. to be
included?
Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts
are not in OnBase
Contract Dates
Effective Date
Termination Notice Period
Contact Information
Contact Info
Review Date *
05/20/2027
Committed Delivery Date
Renewal Date
Expiration Date*
07/20/2027
Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2
Purchasing
Purchasing Approver Purchasing Approved Date
Approval Process
Department Head
JASON CHESSHER
DH Approved Date
02/09/2024
Final Approval
BOCC Approved
BOCC Signed Date
BOCC Agenda Date
02/21/2024
Finance Approver
CHERYL PATTELLI
Legal Counsel
BRUCE BARKER
Finance Approved Date Legal Counsel Approved Date
02/09/2024 02/12/2024
Tyler Ref #
AG 022124
Originator
BFRITZ
Hello