HomeMy WebLinkAbout20250021.tiffResolution
Approve Diagnostic Services Agreement for Cancer Prevention and Early
Detection Screening Services for Women's Wellness Connection Program,
authorize Chair to sign — Banner Health, dba Banner North Colorado Medical Center
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 a Diagnostic Services Agreement for
Cancer Prevention and Early Detection Screening Services 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 Health, dba Banner North Colorado Medical Center,
commencing January 1, 2025, and ending December 31, 2027, with further terms and
conditions being as stated in said agreement, and
Whereas, after review, the Board deems it advisable to approve said agreement, 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 the Diagnostic Services Agreement for Cancer Prevention and Early
Detection Screening Services 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 Health, dba Banner North Colorado Medical Center, be, and
hereby is, approved.
Be it further resolved by the Board that the Chair be, and hereby is, authorized to sign
said agreement.
The Board of County Commissioners of Weld County, Colorado, adopted the above
and foregoing Resolution, on motion duly made and seconded, by the following vote on
the 6th day of January, A.D., 2025, nunc pro tunc January 1, 2025:
Perry L. Buck, Chair: Aye
Scott K. James, Pro -Tern: Aye
Jason S. Maxey: Aye
Lynette Peppler: Aye
Kevin D. Ross: Aye
Approved as to Form:
Bruce Barker, County Attorney
Attest:
Esther E. Gesick, Clerk to the Board
Cc: NL ("SC/BC/SM)
O1 /2.0( /25
2025-0021
HL0058
Con'1va&1 $'910
BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS -AROUND TITLE: WOMEN'S WELLNESS CONNECTION DIAGNOSTIC SERVICES AGREEMENTS
DEPARTMENT: PUBLIC HEALTH AND ENVIRONMENT DATE: DECEMBER 12, 2024
PERSON REQUESTING: JASON CHESSHER, EXECUTIVE DIRECTOR
SHAUN MAY, PHS DIVISION DIRECTOR
Brief description of the problem/issue:
This pass -around includes two agreements to provide diagnostic imaging services for the Women's Wellness
Connection (WWC) program:
1. Banner Imaging Services Colorado, LLC at two locations in Loveland, CO (Skyline and McKee Clinics),
providing both the technical component (performing imaging procedures using qualified personnel and
equipment) and the professional component (interpretation and reporting of imaging results by a
licensed radiologist).
2. Banner Health d/b/a Banner North Colorado Medical Center at the Hospital Outpatient Department
(HOPD) Imaging Technical Services in Greeley, CO, providing only the technical component of imaging
services.
These agreements ensure timely and comprehensive breast and cervical cancer screening and diagnostic
services, including mammograms, ultrasounds, and other diagnostic imaging, for uninsured and underinsured
women in the community.
What options exist for the Board?
1. Approve the agreements to ensure timely and comprehensive imaging services for the Women's
Wellness Connection program.
2. Request modifications to one or both agreements before approval.
3. Decline to approve the agreements.
Consequences:
1. If Approved: Eligible patients will have access to critical imaging services necessary for breast and
cervical cancer screening and diagnosis, enhancing program effectiveness and ensuring
compliance with grant deliverables.
2. If Not Approved: Delayed access to imaging services could hinder program effectiveness, result in
poorer health outcomes, and jeopardize current and future grant funding for the Women's Wellness
Connection program.
Impacts:
These agreements improve access to essential diagnostic services for individuals with limited or no
access to healthcare, ensuring early detection and timely diagnosis of breast and cervical cancers.
Costs (Current Fiscal Year / Ongoing or Subsequent Fiscal Years):
Annual costs will align with program utilization rates and approved budget allocations. Activities will be
conducted by current staff; no additional FTE is being requested.
Recommendation: I recommend approval to place these agreements with Banner Imaging Services Colorado,
LLC, and Banner Health d/b/a Banner North Colorado Medical Center on a future BOCC agenda for formal
consideration.
2025-0021
H1-00
Please note that there are multiple imaging agreements for similar services being brought forward to the
Board. This is because each provider required a separate agreement rather than a single umbrella agreement
which has been used in years past.
Support Recommendation Schedule
Place on BOCC Agenda Work Session Other/Comments:
Perry L. Buck, Pro -Tern
Mike Freeman
Scott K. James
Kevin D. Ross , Chair
Lori Saine
rn‘1(
R
Docusign Envelope ID: EDC06B7E-5973-426F-A3BA-E84A0C0C3A0D
DIAGNOSTIC SERVICES AGREEMENT
FOR WOMEN'S WELLNESS CONNECTION PROGRAM
(314-03-219027)
This Diagnostic Technical Services Agreement (the "Agreement") is entered into as of the signature
dates set forth below, to be effective as of January 1, 2025 ("Effective Date"), by and between the 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") and Banner Health d/b/a
Banner North Colorado Medical Center, an Arizona nonprofit corporation ("Banner") (individually, the
"party" and collectively, the "parties").
RECITALS:
A. WCDPHE provides certain community health services and as part of such services requires
certain medical services, including diagnostic/imaging radiology services to be provided to
patients who qualify for certain health services programs offered by WCDPHE (the
"Designated Patient(s)" under the Tuberculosis Control Program (the "Program");
B. Banner operates North Colorado Medical Center, an acute care hospital facility located in
Greeley, Colorado with a hospital outpatient department Imaging Technical Services -North
Colorado Medical Center located at 2001 70th Ave., Ste 102, Greeley, CO 80634 (together the
"Hospital");
C. Banner provides the technical component of diagnostic imaging/radiology services (the
"Technical Services") at the Hospital;
D. WCDPHE has a separate agreement with Radiology Imaging Associates, P.C. ("RIA") to
provide the professional component of those certain imaging/radiology mammography services
(the "Professional Technical Services") for the Designated Patients at the Hospital;
E. Payments for the Professional Technical Services provided by RIA to the Designated Patients
is addressed via WCDPHE's separate agreement with RIA; and
F. WCDPHE desires to engage Banner to provide the technical component of the diagnostic
imaging/radiology services for the Designated Patient(s) of the Program and Banner desires to
be so engaged, in accordance with the terms and conditions set forth herein.
NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the
parties hereby agree as follows:
AGREEMENT:
1. Banner's Responsibilities.
1.1 Provision of Technical Services. Upon presentation of a voucher as set forth on (Schedule A)
attached hereto and incorporated herein by this reference, and if required, an order of an
appropriately licensed physician (employed or otherwise contracted to provide services to
WCDPHE), BIS shall provide the technical component of such diagnostic imaging/radiology
services (the "Technical 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 Technical Services.
1.2 Results. BIS shall prepare or cause to be prepared written or electronic reports in medical
terminology with respect to all Technical Services. BIS shall, upon request by a treating
1
Docusign Envelope ID: EDC06B7E-5973-426F-A3BA-E84A0O0C3A0D
physician 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 as is necessary for WCDPHE to
make payment for the Technical Services provided.
2. WCDPHE's Responsibilities. WCDPHE shall determine the eligibility of the Designated Patients and
shall provide appropriate information to BIS in order for BIS to provide the Technical Services to the
Designated Patients. Further, WCDPHE shall provide information for the Designated Patients to
schedule the Technical Services through Banner's Central Scheduling Department by calling 970-810-
2007.
3. Compensation. WCDPHE agrees to compensate BIS for the Technical Services at the rate of one
hundred percent (100%) 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 Technical Services are performed.
3.1 Funds Availability. Financial obligations of WCDPHE payable after the 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 WCDPHE to expend funds not otherwise appropriated in each succeeding year.
4. Billin . BIS shall submit invoices monthly to WCDPHE for Technical Services provided to
Designated Patient(s). WCDPHE shall pay such invoices within thirty (30) days following the month
in which the Technical Services were rendered. BIS agrees that BIS shall not, under any circumstances,
bill any Designated Patient(s) or third -party payer for the Technical Services provided pursuant to this
Agreement.
5. Term and Termination. The term of this Agreement shall begin on the Effective Date and shall
continue through December 31, 2027. the term may be extended upon mutual written agreement of
the parties. This Agreement may be terminated by either party at any time without cause and without
penalty by giving the other party at least ten days' prior written notice.
6. Insurance. During the term of this Agreement, each party agrees to secure and maintain in force,
liability insurance with coverages of reasonably appropriate types and amounts. Each party agrees to
produce upon request of the other party certificates of insurance evidencing such coverage.
7. 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.
8. Confidentiality and Nondisclosure. WCDPHE acknowledges that WCDPHE may have access to
confidential and proprietary information of BIS (the "Proprietary Material") through Banner's
performance of the Technical Services for WCDPHE. WCDPHE will keep confidential all Proprietary
Material by exercising the same degree of care toward such material as WCDPHE does with respect
to its own confidential and proprietary information of like importance, but, in any case, using no less
than a reasonable degree of care. WCDPHE will not disclose, distribute, publish, transmit, transferor
disassemble the Proprietary Material or use the Proprietary Material for its own or any other party's
2
Docusign Envelope ID: EDC08B7E-5973-426F-A3BA E84A0C0C3A0D
benefit, except in furtherance of its obligations under this Agreement. WCDPHE will limit access to
Banner's Proprietary Material to only those individuals who need to know such information for
carrying out WCDPHE's obligations hereunder. WCDPHE will ensure that its personnel, agents,
consultants and representatives who are given access to the Proprietary Material will be bound by and
comply with the terms of this Agreement. The nondisclosure provisions of this Agreement will be in
effect during the term of this Agreement and will survive termination, and WCDPHE's duty to hold
the Proprietary Material in confidence will remain in effect until the Proprietary Material no longer
qualifies as confidential information or a trade secret under applicable law. For purposes hereof, the
Proprietary Material includes, but is not limited to, documents, records, reports, data, patient health
information, demographic information, plans, concepts, ideas, processes, procedures, policies,
designs, discoveries, inventions, marketing plans, methodologies, specifications, and other business
information relating to Banner's business, assets, operations or contracts, regardless of whether such
information has been expressly designated as confidential or proprietary. The Proprietary Material
may be provided in written, oral, electronic or other form. The Proprietary Information will not include
any information that (a) is now or becomes generally known or available to the public through no fault
of WCDPHE; (b) was known by WCDPHE before receipt from BIS without any obligation of
confidentiality; (c) is rightfully obtained by WCDPHE from a third party without breach of any
obligation to the disclosing party; or (d) is independently developed by WCDPHE without use of or
reference to any of the Proprietary Material.
9. Independent Contractor Status. Nothing in this Agreement creates an employer -employee
relationship, partnership, franchise, joint venture or agency relationship between the parties, and
WCDPHE will not represent to any third party that any such relationship exists. BIS has and will retain
the right to exercise full control and supervision of the Technical Services, and full control over the
employment, direction, compensation and discharge of all personnel assisting BIS in the performance
of the Technical Services. BIS will be solely responsible for the payment of all social security, self-
employment, federal, state and local income taxes, disability insurance, workers' compensation
insurance, fees, licenses and any other statutory benefits provided to its personnel.
10. Retention and Inspection of Records. All records related to this arrangement will be kept on file by
WCDPHE for a period of four years from the date the record is made or such longer period of time as
may be required by applicable law. Upon reasonable prior notice, WCDPHE will give Banner, or its
authorized representative, and any relevant regulatory agency the ability to inspect, examine, and
audit, during normal business hours, such of WCDPHE's business records as are relevant to this
Agreement. The cost of any BIS inspection, examination, and audit will be at the sole expense of
Banner.
11. Assignment. This Agreement may not be assigned by either party without the prior written consent
of the other party. If consent to an assignment is obtained, this Agreement is binding on the assigns
of the parties to this Agreement. Notwithstanding anything to the contrary in this Agreement, BIS
may assign or otherwise transfer its interest under this Agreement to any "related entity" without the
consent of the other party. For the purposes of this Section, a related entity will be deemed to include
a parent, subsidiary, any entity that acquires all or substantially all of Banner's assets or operations
relating to this Agreement, and the surviving entity of any merger or consolidation involving Banner.
12. Corporate Authority. Each party represents and warrants that the individual executing this Agreement
on behalf of such party is duly authorized to execute and deliver this Agreement on behalf of such
corporation, person, firm, partnership or other entity and that this Agreement is binding upon such
entity in accordance with its terms.
3
Docusign Envelope ID: EDC06B7E-5973-426F-A3BA-E84A0C0C3A0D
13. Force Maieure. Neither party will be liable for any delay in performance or any failure in perfonnance
caused in whole or in part by reason of force majeure, which will be deemed to include the occurrence
of any event beyond the control of the parties, including, without limitation, war (whether an actual
declaration thereof is made or not), sabotage, insurrection, riot and other acts of civil disobedience,
action of a public enemy, laws, regulations or acts of any national, state or local government (or any
agency, subdivision or instrumentality thereof), judicial action, accident, fire, explosion, flood, storm
or act of God.
14. Counterparts. This Agreement may be executed in one or more copies or counterparts, each of which
when signed will be an original, but all of which together will constitute one instrument. Signatures
submitted via telecopy or electronic signature will have the same force and effect as original signatures
and, as such, will be valid and binding upon the parties hereto.
15. Governing Law. This Agreement will be governed by the internal substantive law of the State of
Colorado, without regard for the conflict of law principles thereof.
16. Notice. Any notice required to be given under this Agreement will be in writing, and will be deemed
delivered to the party to whom the notice is sent (a) when personally delivered, (b) one business day
after the same is sent by overnight delivery service, or (c) three days after the same is sent by certified
mail, postage prepaid, addressed to such party at the address that follows or to such other address as
such party may hereinafter designate in writing:
Intended to BIS: Banner Imaging Technical Services Colorado, LLC
2901 N. Central Ave., Suite 160
Phoenix, AZ 85012
Attn: VP, Ambulatory Technical Services
With a copy to: Banner Health
2901 N. Central Avenue, Suite 160
Phoenix, AZ 85012
Attn: General Counsel
Intended to WCDPHE: WCDPHE
1555 N. 17`s Ave.
Greeley, CO 80631
Attn: Wellness Coordinator
17. Governmental Immunity: No term or condition of this contract shall be construed or as a waiver,
express or implied, of any the immunities, benefits, protections or other provisions, of the Colorado
Governmental Immunity Act §§24-10-101 et seq., as applicable now or hereafter amended.
4
Docusign Envelope ID: EDCO6B7E-5973-426F-A3BA-E84A000C3A0D
IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective as of the
Effective Date.
Banner Health d/b/a Banner North Colorado Medical Center
By: ltLuua, 46as
Alan Qualls, Chief Executive Officer
Signature Date: December 13, 2024 I 12:59 PM MST
ATTEST: jerk � 1 BOARD OF COUNTY COMMISSIONERS
Weld ounty rk o e oa ' WE B -BOUNTY, CO.D ADO
BY:
5
, Chair JAN 0 6 2025
2oi5 -OOZt
SCHEDULE A
SERVICES
Medicare Rates and CPT Codes - Updated August 2024
Cancer Prevention and Early Detection ProgramMomen's Wellness Connection Clinical Services
Reimbursable Services and Procedures for June 30, 2024 to June 29, 202S
Listed below are allowable procedures and the corresponding CPT codes for use in the Cancer
(CPED)/Women's Wellness Connection (VWVC) Clinical Services program These rates are
for Medicare and Medicaid website. Rates are incorporated into the program's Bundled Payment
Prevention and Early Detection
based on information found on the Centers
System (BPS) at the beginning of each
and to aid in negotiating
o cancer screening and diagnostics of
program, Please contact your CDPHE
fiscal year. Codes are provided to show what services are covered through VWVC Clinical Services
subcontracts. Reimbursement for treatment services is not allowed. Additional CPT codes related
the breast and cervix may be eligible for reimbursement through the CPEDNWVC Clinical Services
CPT CODES
OFFICE VISITS
End
Notes
2024 CO
Rates
2024 Prot
(26)
12024 Tech
(TR
99202
99203
New patient; expanded history, exam, straightforward decision -making; 15.29
57407
5113 82
99204
New Patient; comprehensive history, exam, moderate complexity decision -making;
45-59 minutes
1
5170.26
99205
New patient; comprehensive history, exam, high complexity decision -making; 60-74
minutes
1
$224 32
99211
99212
Established patient; evaluatkm and management. may not require presence of
52419
55809
99213
Established Patient; expanded history, exam, straightforward decision -making; 20.29
minutes
59299
98214
Established Patient detailed history, exam, moderately complex decision -making; 30
39 minutes
5131 02
99385
Initial comprehensive preventive medicine evaluation and management; history,
examination, counseling and guidance, risk factor reduction, ordering of appropriate
Immunizations and lab procedures; 18 to 39 years of age
2
i5t259059lly
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
tnlentionally
left blank
99395
Periodic comprehensive preventive medicine evaluation and management; history,
examination, counseling and guidance, risk factor reduction, ordering of appropriate
immunizations and lab procedures: 18 to 39 years of age
2
intentionally
left blank
Dacuc�gn En,,elope ID EDC0687E-5973426F-A38 AE64A0C0C3A0D
99396
Same as 99395 but 40 to 64 years of age
2
Intentionally
left blank
99397
Same as 99395, bur 65 years of age or older
2
intentionally
left blank
CPT CODES
BREAST SCREENING AND DIAGNOSTIC SERVICES
End
Notes
2024 CO
Rates
2024 Prof
(26)
2024 Tech
(TC)
76098
76641
Radiological examination. surgical specmen
Ultrasound, complete examination of breast including axilla, unilateral
$44 18
S106 49
51516
534 71
52902
$71 78
76642
76942
Ultrasound, limned examination of breast including axilla. unilateral
Ultrasonic guidance for needle placement. Imaging supervision and interpretation
3
3
$87 99
$5969
$32 33
$2997
$5566
$29 72
19000
Puncture aspiration of cyst of breast
$103 42
19001
19100
Puncture aspiration of cyst of breast, each additional cyst, used with 19000
Breast biopsy, percutaneous, needle core. not using imaging guidance
52869
515280
19101
Excision Procedures on the Breast
5335 53
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
$531 44
19125
Excision of breast lesion identified by preoperative placement of radiological marker,
open; single lesion
$58471
19126
Excision of breast lesion identified by preoperative placement of radiological marker,
open; each additional lesion separately identified by a preoperative radiological
marker
NA
19081
8reast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous; stereotactic guidance, first lesion
7
$513 11
19082
Breast biopsy, with placement of localization device and imaging of biopsy
specimen. percutaneous, slereolaclic guidance; each additional lesion
7
$396 19
19083
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous: ultrasound guidance; first lesion
7
551184
19084
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous; ultrasound guidance; each additional lesion
7
$390 11
19085
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous; magnetic resonance guidance; first lesion
7
E788 69
19086
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous; magnetic resonance guidance; each additional lesion
7
$610 16
19281
Placement of breast localization device, percutaneous; mammographic guidance;
first lesion
8
$248 37
19282
Placement of breast localization device, percutaneous; mammographic guidance,
each additional lesion
8
517859
19283
Placement of breast localization device, percutaneous; steieotactic guidance; first
lesion
8
S268 37
19284
Placement of breast localization device, percutaneous, slemotactic guidance; each
additional lesion
8
$195 72
19285
Placement of breast localization device, percutaneous; ultrasound guidance; first
lesion
8
537859
19288
Placement of breast localization device, percutaneous; ultrasound guidance; each
additional lesion
B
531038
19287
Placement of breast localization device, percutaneous; magnetic resonance
guidance; first lesion
8
f654 12
19288
Placement of breast localization device, percutaneous; magnetic resonance
guidance, each additional lesion
8
550515
38505
10021
Needle biopsy of axillary lymph node
Fine needle aspiration without imaging guidance, first lesion
5179 03
$103 96
10004
10005
Fine needle aspiration biopsy without imaging guidance, each additional lesion
Fine needle aspiration blop, Including ultrasound guidance, first lesion
$52 85
6137 87
10008
10007
Fine needle aspiration biopsy including ultrasound guidance. each additional lesion
Fine needle aspiration biopsy including fluoroscoplcguidance, first lesion
$6084
531496
f
10008
10009
Fine needle aspiration biopsy including fluoroscopic guidance, each additional lesion
Fine needle aspiration biopsy including CT guidance, first lesion
5'45 37
544327
f
10010
Fine needle aspiration biopsy including CT guidance, ea. additional lesion
524306
10011
10012
F
Fine needle aspiration Mnm inr.Frrfinrg MRI Orridanro, h. lecinn
Fine needle aspiration biopsy including MRI guidance, each additional lesion
9
9
5443 27
524306
i
68172
Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to
determine adequacy of specimenfsl, first evaluation episode
55735
$3484 522 7'
88177
Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to
determine adequacy of scimenfs), each separate additional evaluation episode pe
53014
$21 35
$e 76
88173
88305
Cytopathology, evaluation of fine needle aspirate, interpretation and report
Surgical pathology gross and microscopic examination
517350
57409
$6857
53688
5104 93
53743
88307
Surgical pathology gross and microscopic examination; requiring microscopic
evaluation of surgical margins
529994
58047
52194 /
00400
Anesthesia for procedures on the integumentary system, anterior trunk, not
otherwise specified Medicare Base Units = 3
14
$20.51
77053
Mammary duclogram or galactogram, single dud
S5602
$1719
538 63
Dowygn Envelope ID EDC08e7E-5973.426F-A3eA-E94A000C3A0D
77046
Magnetic resonance imaging (MRI), breast, without contrast, unilateral REQUIRES
WWC PREAPPROVAL
8
522709
58846
5158 63
77047
Magnetic resonance imaging (MRI), breast, without contrast, bilateral REQUIRES
VWVC PREAPPROVAL.
8
3233 45
57552
$' 57 93
77048
Magnetic resonance imaging (MRI), breast, including CAD, with and without
contrast, unilateral REQUIRES WWC PREAPPROVAL,
6
335694
39943
5259 51
77049
77063
Magnetic resonance imaging (MRI), breast, including CAD, with and without
8
4
3385 92
55358
$108 87
52832
5257 05
52524
7)065
Diagnostic Mammography, unilateral, includes CAD
513021
53844
591 76
77066
77087
Diagnostic Mammography, bilateral, includes CAD
Screening Mammography, bilateral
3164 82
513308
34720
53807
511762
59702
G0279
Diagnosticdigitai breast tomosynthesis, unilateral or bilateral (diagnostic 3D
mammography)
5
54885
52832
520 33
Various
To include any pre -operative testing procedures medically necessary for the planned
surgical procedure (e g complete blood count, urinalysis, pregnancy lest, pre -
etc)
CPT
CPT CODES
CERVICAL SCREENING AND DIAGNOSTIC SERVICES
End
Notes
2024 CO
Rates
2024 Prof
(26)
2024 Tech
(TC)
88164
Cytopathology (conventional Pap test) slides cervical or vaginal reported in
Bethesda System. manual screening under physician supervision
$ t 7 76
88165
Cytopathology (conventional Pap test), slides cervical or vaginal repotted in
Bethesda System, manual screening and rescreening under physician supervision
$42 22
88141
Cytopathology (conventional Pap test). cervical or vaginal, any reporting system,
requiring inlerprefalion by physician
$24.37
88142
Cytopathology (liquid -based Pap lest) cervical or vaginal, collected in preservative
fluid, automated thin layer preparation: manual screening under physcian
$20 26
88143
Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin
layer preparation; manual screening and rescreening under physician supervision
$23 04
88174
Cylopalhology, cervical or vaginal, collected in preservative fluid, automated thin
layer preparation; screening by automated system, under physician supervision
$25 37
88175
Cylopalhology, cervical or vaginal, collected in preservative fluid, automated thin
layer preparation; screening by automated system and manual rescreening, under
physician supervision
S26 61
87624
Human Papillomavirus (HPV) high-nsk pes
10
$35 09
87625
Human Papillomavirus, types 16 and 18 only
10
542.55
L�a:w�yn Envelope ID EOCIY'B7E 5573 2O,3iAEMA0CIIC
57452
ColW0Y of the Cervix
$130 20
57454
Colpos_py of to cervix, with biopsy and endooervlcal curettage
$172 34
57455
57456
Colposcopy of the cervix, with biopsy
Colposcopy of the cervix, with endocervcal curettage
$16594
$156 49
57460
Colposcopy with loop electrode bwpsy(s) of the cervix Requires WWC Preapproval
Unless Done Atter HSIL or AIS Pap test
$323 46
57461
Colposcopy with loop electrode cdnizalion of the cervix Requires WWC Preapproval
urYess done alter HSIL or AIS Pap lest
$359 67
57500
Cervical biopsy, single or multiple, or local excision of lesim, with or without
fulguration (separate procedure) Use Ihis code for ceriv polyp removal
$158 99
57505
Endocervical curettage (not done as pan of a dilation and curettage)
$161 11
57520
Conization of cervix, with or without fulguration, with or without dilation and
curettage, with or without repair: cold knife or laser
11
$364 33
57522
Loop electrode excision procedure
11
$31204
58100
Endomelnai sampling (biopsy) with or without endocervical sampling (biopsy),
without cervical dilation, any method (separate procedure) Only for diagnostic
following AGC Pap
$103 94
58110
88305
,purposes
Endometrial sampling (biopsy) performed in conjunction wdh Colposcopy (List
separate, in addition to code for primary procedure). Only for diagnostic purposes
$50 BO
$74 09
$36 66
$37 43
88331
Pathology consultation during surgery, firs) tissue block, wit frozen section(s),
single specimen
$104 20
$60.61
$43 39
88332
88341
Pathology oonoulldlion during ourgory, ouch additional ticcuo bra , with frozen
$56.10
$94.43
$29.89
$2748
$26.21
$66 95
88342
80360
Immunohislochemistry antibody slide
Morphomelnc analysis, tumor immunohislochemislry, pre &mama, manuei
$110 27
$125.11
$34 28
$40.71
$75.99
$84 40
88361
Moti:drr Mc anaysis, tumor immunohislochemistry, pre specimen; using computer
assisted technology
$12391
$42 67
881 24
99070
Supplies and materials (except spectacles), provitletl by the physician over and
above Ihose usually inUuded with the office visit orolrler services rendered (list
drugs, trays, supplies, or materials provided)
Venous
Pre -operative testing; CBC, urinalysis, pregnancy lest, etc These procedures should
be medically necessary for the planned surgical procedure
Dorai in Encamps ID EDCOBe7E-5873-126F-A30.84A000MAOD
GPT CODE: CONCIOUS SEDATION ANESTHESIA I End 221 CO
,; Notee Rates.
00400 Anesthesia for procedures on Ine mtegtimenlary system, anterior trunk, not otherwise specified
99158 10-22 minutes for individuals 5 years or ol0er $74 08
99157 'For each additional 15min
00940 1Anesthesra for vaginal procedures (inaudn9 biopsy of tabu, vagina, cervix orendomelrium); not otherwise specs,
CPT CODES PATHOLOGYFOR BOTH BREASTANDCERVICALCANCERSCREENING AND End 2024 CO 024Prof(2s2024Ter.h(TC)
DIAGNOSTICS Notes Rates
12 $58.99
024 Prof (24 2024 Tech (TC
87426
87635
88365
88364
88386
86387
88373
88374
88368
88369
88377
Various
COVID-19 infectious agent detection by nuclei add A or , amplified probe
technique
15
$35 33
COVID-19 infectious agent antigen detection by immunoassay technique, qualitative 15
or semiquanlilative
In situ hybridization (eg,FISH), per specimen; initial single probe stain procedure I
$51.31
$184 93
$42.07 1$142.86
In situ hybridization (eg,FISH), per specimen; each additional single probe stain I
yrocedure
$139.01
$33 23
$105.78
In situ hybndrzation (eg,FISH), per specimen; each multiplex probe stain procedure I
$283.51560.38
$223 13
Manometric analysis, In situ hybridization computer -assisted, per specimen, initial I
single probe stain procedure
$116.18
$32 48
$83.70
Manometric analysis, in situ hybridization, computer assisted, per specimen, each
additional probe stain procedure
$70 21
$24.72
$45.49
Manometric analysis, in situ hybridization, computer -assisted, per specimen, each
multiplex stain procedure
$300 95
$41.29
$259.88
Manometric analysis, in situ hybridization, manual, per specimen, initial single
probe stain procedure
$154 09
5C 37
$112.72
MorphomeMc analysis, in situ hybridization, manual, per specimen, each additional
probe slain procedure
$133 75
$32.88
$100.87
Moryhometnc anaysis, n srtu hy070izahon, manual, per specimen, each multiplex
stain procedure
$413.32
$82.87
$350.84
Pre -operative testing, CBC, urinalysis, pregnancy lest, etc. These procedures should
be medically necessary for the planned surgical procedure
CPT CODER CONICAL U.K. AND PROCEN,REs SPECIFICALLY NOT ALLOWED
Arty �realment of breast carcinoma in situ, breast cancer, cervical Intraepithelial
neoplasia and cervical cancer
77061, 77062 reasl tomosynthesis. as screening, diagnostic, undaleratbdateral These
procedures have not been approved for coverage by CPEDI V VC
t3
87823 Human Papillomavirus, low-nsk types
END NOTES FOR till C CLINICAL SERVICES
1
—2—The
AU consultations should be billed through the standard 'new patient' office visit CPT codes 99202-99205 Consultations billed as 99204
99383 codes shall be reimbursed at or below the 975a rate. and 9939X codes shall be reimbursed al or below the 99213 rale.
3
4
Fora bilateral breast ultrasound, a modifier 50 may be added to either 76641 or 76642 to indicate a bilateral procedure. The Medicare
Physician Fee Schedule assigns a -Ill bilateral indicator to both CPT codes 76641 and 76642 which means that Medicare will allow 150
List separately In addition to code for pnmary procedure 77067-
5
6
List separate, in addition to 77065 or 77067.
Breast MRI can be reimbursed by the in conjunction with a mammogram when a client has a BACA gene mutation, a first -degree
7
8
Codes 19081-19066 are to be used for breast biopsies that include image guidance, placement of localization device, and imaging of
Codes 19I81-19288 are for Image guidance placement of localization day. without image guided baps, These codes should not be
9
10
For CPT 10011 use the reimbursement rate for CPT code 10009 For CPT 10012 use the reimbursement rale for CPT code 10010
HPV DNA testing is not a reimbursable lest for women under 30 years of ego
11
A LEEP or conizalion 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 conizalion of the cervix as a treatment procedure cannot be reimbursed by
12
13
Example: If procedure is 50 minutes, code 99158 • (99157 x 2) No separate charge snowed d procedure
Theseprocedures have not been approved for coverage by Medicare. Please see code 77083 as the approved code for screening
14
The Cartier specific Medicare anesthesia conversion rates are available here: Ane,thesiolog stg e_nler
Medicare's methodology for the payment of anesthesia services are outlined In the Medicare Claims Processing Manual, Chapter 12
pages 99-101, available here, htlpY/www.cros.11hs.gov/manuals/downlgads/Gm104c I2.pdf
15
Slates have received federal funding and lest 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 lest is negative If the COVID-1f testis positive, your organization will need to have a plan for following up
to make sure the required procedure gets done at a later date.
12
Docusign Envelope ID: EDC06B7E-5973-426F-A3BA-E64A0C0C3A0D
SCHEDULE B
SAMPLE
VOUCHER
WELD COUNTY DEPARTMENT Of PUBLIC HEALTH AND ENVIRONMENT
1555 North 17Th Avenue. Greeley, CO 00631 www.weldhealth.org
Radiology Service Voucher
This voucher is for the following patient who has been confirmed as eligible for.
F.,re rup,in es purq 7gaperr'nas yur snn consfirmaths desiM1le p.w.
❑ Women's Wellness Connection Program 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:
frown hs nprapinda
u Summit View Medical Commons
20017O Avenue, Greeley, CO 80634
(970)810-6070
Appointment da'"rne:
Fechn de (n rita
Patient's name:
.V'nmAre<kfpaNerue
Covered service for this visit:
Servldo wMnin pare nro dto
❑ North Colorado Medical Center
1801 le Street, Greeley, CO 80631
(970) 810-4121
Patient's Date of Birth:
•All other services will require prior authorization.
Tusks ones sr ktos se requleren erroritaclbn previa.
NOTE; This',ocher expires 60 days after data of issue.
Issue date: Authorized Signature:
tiervice Provider. oleayc lilt Weld bolt *s an insurance for the *hove listed service only:
Wetd County Department ofl'ublic Health
Attn: Contract Billing
1555 No. l7th Avenue, Greeley, CO 8063i
i.' you have nny questions qr need to reuhedule, please call (1701104fid20.
Si nrreAriene nlRurus pregunrn • lirne qur rnncelnr In rftn, pur�nvor (Lome (9i0J l0d d�10
Contract For r
Entity Information
Entity Name *
BANNER HEALTH
Entity ID*
@00013111
Q New Entity?
Contract Name* Contract ID
WOMEN'S WELLNESS CONNECTION DIAGNOSTIC 8971
SERVICES AGREEMENT - NCMC LOCATION
Contract Status
CTB REVIEW
Contract Lead *
BFRITZ
Contract Lead Email
bfritz@weld.gov;Health-
Contracts@weld.gov
Parent Contract ID
Requires Board Approval
YES
Department Project #
Contract Description*
WOMEN'S WELLNESS CONNECTION DIAGNOSTIC SERVICES AGREEMENT - NCMC LOCATION
Contract Description 2
Contract Type *
AGREEMENT
Amount*
$0.00
Renewable*
NO
Automatic Renewal
Grant
IGA
Department
HEALTH
Department Email
CM-Health@weld.gov
Department Head Email
CM -Health- Does Contract require Purchasing Dept. to be
DeptHead@weld.gov included?
Requested BOCC Agenda Due Date
Date* 01 /02/2025
01/06/2025
Will a work session with BOCC be required?*
NO
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY@WEL
D.GOV
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
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
Review Date
11/01/2025
Committed Delivery Date
Renewal Date
Expiration Date*
12/31/2025
Contact Info
Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2
Purchasing
Purchasing Approver Purchasing Approved Date
Approval Process
Department Head Finance Approver Legal Counsel
JASON CHESSHER CHERYL PATTELLI BYRON HOWELL
DH Approved Date Finance Approved Date Legal Counsel Approved Date
12/18/2024 12/18/2024 12/18/2024
Final Approval
BOCC Approved Tyler Ref #
AG 010625
BOCC Signed Date Originator
BFRITZ
BOCC Agenda Date
01/06/2025
Hello