HomeMy WebLinkAbout20250022.tiffResolution
Approve Diagnostic Services Agreement for Cancer Prevention and Early
Detection Screening Services for Women's Wellness Connection Program,
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 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 Imaging Services Colorado, LLC, 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 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 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-Tem: Aye
Jason S. Maxey: Aye
Lynette Peppier: Aye
Kevin D. Ross: Aye
Approved as to Form:
Bruce Barker, County Attorney
Attest:
Esther E. Gesick, Clerk to the Board
cc:!-(L(5c/13j/5K'
o'/2q/25
2025-0022
HL0058
Con C+ (1 911
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. -
2025-0022
Vco
H1-005�
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 Aqenda Work Session Other/Comments:
Perry L. Buck, Pro-Tem
Mike Freeman
Scott K. James
Kevin D. Ross , Chair
Lori Saine
OrP
Ce
tqt
R
Docusign Envelope ID: 7F7A4FDB-1166-4E65-8860-2C21B8E891BD
DIAGNOSTIC SERVICES AGREEMENT
FOR WOMEN'S WELLNESS CONNECTION PROGRAM
(0556-03-219023)
This Diagnostic 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 Imaging Services
Colorado, a Colorado limited liability company ("BIS") (individually, the "party" and collectively, the
"parties").
RECITALS:
A. BIS operates certain outpatient clinics providing radiology services clinics located at 1900 N
Boise Ave, Ste 110, Loveland, CO 80538 and 2555 E. 13th St., Ste 100, Loveland, CO 80537
(the "Clinics").
B. BIS provides the technical and professional component of diagnostic imaging/radiology
services (the "Services") at the Clinics.
C. WCDPHE desires to retain a qualified provider to provide certain imaging/radiology (the
"Designated Patients").
D. WCDPHE desires to engage BIS to provide the technical and professional components of the
diagnostic imaging/radiology services for the Designated Patient(s) and BIS 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 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 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.
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 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 Services provided.
Docusign Envelope ID: 7F7A4FDB-1166-4E65-8860-2C21 B8E891 BD
2. WCDPI IE'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 Services to the Designated
Patients. Further, WCDPHE shall provide information for the Designated Patients to schedule the
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 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. Billing. 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.
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 came 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 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, transfer or
disassemble the Proprietary Material or use the Proprietary Material for its own or any other party's
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
2
Docusign Envelope ID: 7F7A4FDB-1166-4E65-8860-2C21B8E891BD
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 Services, and full control over the employment,
direction, compensation and discharge of all personnel assisting BIS in the performance of the
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.
13. Force Majeure. Neither party will be liable for any delay in performance or any failure in performance
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.
3
Docusign Envelope ID 7F7A4FDB-1166-4E65-8860-2C21B8E891BD
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 Services Colorado, LLC
2901 N. Central Ave., Suite 160
Phoenix, AZ 85012
Attn: VP, Ambulatory 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. 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: 7F7A4FDB-1166-4E65-8860-2C21B8E891BD
IN WITNESS WHEREOF, the parties hereto have executed this Agreement effective as of the
Effective Date.
Banner Imaging Services Colorado, LLC A Colorado Limited Liability Company
By: JMI Cef�,
Jim Cote
Vice President, Ambulatory Services
Signature Date: December 14, 2024 I 3:06 PM MST
-1
ATTEST: dItifm) � C J :
Weld County erk to the Board WELD COUNTY, COI�R ADO
puty Clerk to the Boar
BY:
5
BOARD OF COUNTY COMMISSIONERS
k, Chair JAN 0 6 2025
ZO25-00Z2,
SCHEDULERES SERVIC
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 25, 2025
Listed below are allowable procedures and the corresponding CPT codes for use in the Cancer
(CPED)/Women's Wellness Connection (VW1/C) Clinical Services program These rates are
for Medicare and Medicaid websde. 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
Services and to aid in negotiating
to cancer screening and diagnostics of
program. Please contact your CDPHE
fiscal year. Codes are provided to show what services are covered through WWC Clinical
subcontracts- Reimbursement for treatment services is not allowed Additional CPT codes related
the breast ar d cervix may be eligible for reimbursement through the CPEONVWC Clinical Services
CPT CODES
OFFI CEVI SI TS
End
Nobs
2024 CO
Rates
2024 Prof
(28)
2024 Tech
(TC)
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
517026
99205
New patient; comprehensive h istory, exam, high complexity decision -making, 60-74
minutes
1
5224 32
99211
Established patient; evaluation and management, may not require presence of
physician; presenting problems are minimal
524.19
99212
Established patient; history, exam, straightforward decision -making; 10-19 minutes
Ma 09
99213
Established Patient; expanded history, exam, Straightforward decision -making; 20-29
minutes
S92 99
99214
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 l0 39 years of age
2
intentionally
left blank
99386
Same as 99385, but 4010 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 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
Cocusign Envelope ID 1F IMF DB- 1 166-4E65 9860.2C21B8E8918U
99396
Sam' as 99395 but 40 to 64 years of age
2
intentionally
left blank
99397
Same as 99395, but 65 years of age or older
2
intentionally
left blank
End
Notes
2024 CO
Rates
2024
4281
Prof
(TC)
2024 Tech
BREAST SCREENING
AND DIAGNOSTIC SERVICES
CPT CODES
544 18
515 16
529 C2
76098
Radiological examination, surgical speamen
76641
Ultrasound, complete examination of breast including axilla, unilateral
$5106 49
S34 71
$71 78
76642
Ultrasound, limited examination of breast includinjaxilla, unilateral
3 $58799
1532 33
555 66
76942
Ultrasonic guidance for needle placement, imaging supervision and interpretation e
3
j$5969
4529 97
579 72
19000
Puncture aspiration of cyst of breast
5'03 42
19001
Puncture aspiration of cyst of breast, each additional cyst, used with 19000
�S2669
19100
Breast biopsy, percutaneous, needle core, not using imaginaguidance
5152 80
5335 53
Excision Procedures on the Breast
19101
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, singie lesion
5584 71
19126
Excision of breast lesion identified by preoperative placement of radiological marker,
open, each additional lesion separately ident fed by a preoperative radiological
marker
NA
19081
Breast 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; stereotactic guidance; each additional lesion
7
5396 19
,'
19083
Breast
specimen,
biopsy,
with placement of localization device and imaging of biopsy
percutaneous, ultrasound guidance; first lesion
7
$511 64
_
19084
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous; ultrasound guidance; each additional lesion
7
5390 11
19085
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous, magnetic resonance guidance; first lesion
7
5786 69
Breast biopsy, with placement of localization device and imaging of biopsy
specimen, percutaneous; magnetic resonance guidance, each additional lesion
7
5610 18
19086
19281
Placement of breast localization device, percutaneous; mammographic guidance;
first lesion
8
$248 37 1
Oocus'gu Envelope ID 7F 7A4F0B-11554E6S88ol}?t:71 B8E89180
19282
Placement of breast localization device percutaneous, mammographic guidance;
each additional lesion
8
S1/6 Sg
19283
Placement of breast localization device, percutaneous; stereotactic guidance, first
lesion
8
5266 3/
19284
4
Placement of breast localization device, percutaneous; stereotactic guidance, ea&
additional lesion
8
5195 12
19285
Placement of breast localization device, percutaneous, ultrasound guidance, 'irst
lesion
8
5378 59
19286
Placement of breast localization device percutaneous; ultrasound guidance, each
additional lesion
8
=31036
19287
Placement of breast localization device percutaneous, magnetic resonance
guidance: first lesion
8
8654 12
19288
Placement of breast localization device, percutaneous, magnetic resonance
guidance: each additional lesion
8
$505 15
38505
Needle biopsy of axillary lymph node
5179 03
10021
Fine needle aspiration without imaging guidance. first lesion
$103 96
10004
Fine needle aspiration biopsy without imaging guidance each additional lesion
$5285
10005
Fine needle aspiration biopsy including ultrasound guidance, first lesion
$137 87
I
10006
Fine needle aspiration biopsy including ultrasound guidance, each additiona lesion
$6084
10007
Fine needle aspiration biopsy including fluoroscopic guidance, first lesion
5314 96
10008
Fine needle aspiration biopsy including fluoroscopic guidance, each additional lesion
'5443
$115 37
10009
Fine needle aspiration biopsy including CT guidance, first lesion
27
10010
F ne needle aspiration biopsy including CT guidance, each additional lesion
)24306
10011
10012
Fine needle aspiration broosy includinnMRI.guidance.
Till guidance.
first lesion
9
$443 27
Fine needle aspiration biopsy in d ng
each aliona lesion
9
`
x$243
06
88172
Cytopathology, evaluation of fine needle aspirate: immediate cytohistologic study to
determine adequacy of specimen(s), first evaluation episode
$57 35
534 64
$22 71
88177
Cylopathotogy, evaluation of fine needle aspirate: immediate cytohistologic study to
determineadequacyof specimen(s), each separate additional evaluation episode
$3314
'
S2138
$8 76
88173
evaluation cf fine needle aspirate, interpretation and report
51 73 50
568 57
$104 93
88305
�Cytopathology,
Surgical pathology. gross and microscopic examination
574 09
53666
$37 43
88307
Surgical pathology, gross and microscopic examination; requinng microscopic
evaluation of surgical margins
$299 94
$60 47
)219 47
00400
Anesthesia for procedures on the integumentary system, anterior trunk, not
otherwise specified Medicare Base Units = 3
14
$20 51
L
77053
Mammary ductogram or galactogram, single dud
« J..
$
_S3883
Docusign Envelcpe ID 7F7A4FDB-1166-4E6r8860-2C2188E8918D
77048
Magnetic resonance imaging (MRI), breast, without contrast, unilateral REQUIRES
VWVC PREAPPROVAL
6
5227 09
$68 46
515863
77047
Magnetic resonance imaging (MRI), breast. without contrast, bilateral REQUIRES
VWVC PREAPPROVAL.
6
$233 45
_
$75 52
$157 93
77048
Magnetic resonance imaging (MRI), breast, including CAD, with and without
contrast, unilateral REQUIRES VWVC PREAPPROVAL
6
$358 94
599 43
5259 51
77049
Magnetic resonance imaging (MRI), breast, including CAD, with and without
contrast, bilateral REQUIRES WWC PREAPPROVAL
6
$365 92
5108 87
525705
77063
Screening digital breast tomosynthesis, bilateral (3D mammography)
4
553 56
$2832
$2524
77065
Diagnostic Mammography. unilateral, includes CAD
5130 21
538 44
$91 76
77068
Diagnostic Mammography, bilateral, includes CAD l
5164 82
547 20
$11762
77067
Screening Mammography, bilatera! 1
$133 08
$36 07
597 02
G0279
Diagnostic digital breast tomosynthesis, unilateral or bilateral (diagnostic 3D
mammography)
5
548 65
$28 32
$20 33
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 )
CPT CODES
CERVICAL SCREENING AND DIAGNOSTIC SERVICES
End
Notes
2024 CO
Rates
2024
Prof
(LTC)
2024
Tech
88164
Cytopathology (conventional Pap test), slides cervical or vaginal reported in
Bethesda System manual screening under physiaan supervision
$17 76
88165
Cytopathology (conventional Pap test), slides cervical or vaginal reported In
Bethesda System, manual screening and rescreening under physician supervision
$42 22
88141
Cytopathology (conventional Pap test), cervical or vaginal, any reporting system,
requiting interpretation by physiaan
$24 37
88142
Cytopathology (liquid -based Pap lest) cervical or vaginal, collected in preservative (
fluid, automated thin layer preparation, manual screening under physician
$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
' Cytopathology, cervical or vaginal, collected in preservative fluid, automated thin
layer preparation screening by automated system, under physloan supervision
$25 37
88175
Cytopathology, cervica' or vaginal, collected in preservative fluid, automated thin
layer preparation; screening by automated system and manual rescreening, under
physician supervision
$26 61
87624
Human Papillomavirus (HPV) high -risk types
10
$35 09
87625
Human Papillorravirus, types 16 and 18 only
10 _1540 55
C?acueign Envelope :D 7F?A4FDB-1166-4E65-ade1 7O:71RREd9BD
57452
Colposcopy of the cervix
$130 20
57454
Colposcopy of the cervix, with blopsyr and endocervical curettage
$' 72 34
57455
Colposcopy of the cervix, with biopsy
$165 94
57456
Colposcopy of the cervix, with endocervical curettage
$156.49
57460
Colposcopy with loop electrode biopsy(s) of the cervix Requires WYVC Preapproval
Unless Done After HSIL or AIS Pap test
$323 46
57461
Colposcopy with loop electrode conization of the cervix Requires WWC Preapproval
un.ess done after HSIL or AIS Pap test
$359 67
57500
Cervical biopsy, single or multiple, or local excision of lesion, with or without
►ulguration (separate procedure) Use this code for cervical polyp removal
$158 99
57505
Endocervical curettage (not done as part o' a dilation and curettage)
$!61.11
1
57520
Conrzatron of cervix, with or without fulguration, with or without dilation and
curettage, with or without repair, cold knife or laser
11
5364 33
157522
Loop electrode excision procedure
11
$312 04
58100
Endometrial sampling (biopsy) with or without endocervical sampling (biopsy).
without cervical dilation, any method (separate procedure) Only for diagnostic
purposes following AGC Pap
5'03 94
58110
Endometnal sampling (biopsy) performed
separately in addition to code for
following AGC Pap
$50 80
in conjunction with colposcopy (List
primary procedure) Only for diagnostic purposes
88305
Surgical pathoOgy, gross and microscopic examination
S74 09
$36 66
$37 43
88331
Pathology consultation during surgery, first tissue block, with frozen section(s),
sing e specimen
$104 20
$60 81
$43 39
Foill?
Pathology rnncirltalinn Minn0 crrrOPry e i:h arirlhf!nnal tissue block. with frozen
sect:on(s)
$56.10
$29.89
$26 21
88341
Immunohistochemistry antibody slide
$94 43
527 48
$66.95
88342
Immunohistochemistry antibody slide
$110.27
$34 28
575 99
88360
Morphometric anatys's, tumor immunohistochemistry, pre spec men, manual
$125 11
$40 71
$84 40
88361
Morphometnc analysis, tumor immunoh stochemistry, pre specimen, using compute
assisted technology
$123 91
$42 67
$81 24
99070
Supplies and materials (except spectacles), provided by the physician over and
above those usually included with the office visit or other sery ces rendered (list
drugs, trays, supplies. or materials provided)
Various
Pre -operative testing; CBC urinalysis, pregnancy test, etc These procedures should
be medically necessary for the planned surgical procedure
10
Oocusign Envelope 'D 7F 7A4F0B-1166 4E65-8960-2c2188E891BO
CPT CODE$ CONCIOUS SEDATION ANESTHESIA
00400
End
Notes
2024 CO
Rates
2024 Prof (26 2024 Tech (TC
Anesthesia for procedures on the integumentary system. antenor trunk, not otherwise specified
99156
10-22 minutes for individuals 5 years or older
For each additional 15 minutes
$74.06
99157
12 1$58.99
00940 !Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix orendomelrium). not otherwise €pecitled
CPT CODES PATHOLOGY FOR BOTH BREAST AND CERVICALCANCER SCREENING AND
DIAGNOSTICS
87426
87635
88365
88364
88366
88367
88373
88374
88368
88369
88377
Various
End
Notes
2024 CO
Rates
024 Prof (26
2024 Tech (TC)
COvID-19 infectious agent detection by nuclei acid DNA or RNA; amplified probe
technique
15
$35.33
COVID-19 infectious agent antigen detection by immunoassay technique; qualitative
or semiquantitative
15
$51 31
In situ hybridization (eg,FISH), persaeamen, initial single probe stain procedure
$184.93 i
$42.07 j$142.86
In situ hybridization (eg,FISH), per specimen; each additional single probe stain
procedure
$139.01
w
$33 23
$105.78
. i
In situ hybridization (eg,FISH), per specimen; each multiplex probe stain procedure s
$283.51
560.38
$223 13
Morphometnc analysis, in situ hybridization, computer -assisted, per specimen, initial I
single probe stain procedure
$116 18
$32.48
583.70
Morphometnc analysis, in situ hybridization, computer -assisted, per specimen, each
additional probe slain procedure
$70.21
$24 72
$45 49
Morphometric analysis, in situ hybridization, computer -assisted, per specimen, each
multiplex stain procedure
$300.95
$41 29
$259.66
Morphometric analysis, in situ hybridization, manual, per specimen, initial single
probe stain procedure _
$154.09
$41.37
$112.72
Morphometnc analysis, in situ hybridization, manual, per specimen, each additional
probe stain procedure
$133.75
$32.88
$100.87
Morphometnc anaysis, in situ hybridtzatlon, manual, per specimen, each multiplex
stain procedure
$413 32
$62 67
$35064
Pre -operative testing; CBC, urinalysis, pregnancy test, etc. These procedures should
be medically necessary for the planned surgical procedure.
CPT CODES CLINICAL SERVICES As;D PROCEDURES SPECIFICALLY NOT ALLOWED
11
Docvsign Envelope ID 7F7A4FDB-1166.4E65-8960-2C2188EH918D
Any
Treatment of breast carcinoma in situ, breast cancer, cervical intraepithelial
neoplasia and cervical cancer
I
77061,
77062
Breast tomosynthesis, as screening, diagnostic, unilateral/b:lateral These
procedures have not been approved for coverage by CPE DIWWC
. 3
87623
Human Papillomavirus, low-nsk types
ENO NOTES FOR WWC CLINICAL SERVICES
1
All consultations should be billed through the standard new patient' office visit CPT codes 99202-99205. Consultations billed as 99204
2
The 9938X codes shall be reimbursed at or below the 99203 rate, and 9939X codes shaN be reimbursed at or below the 99213 rate
3
For a bilateral breast ultrasound, a modifier 50 may be added to either 76641 or 76642 to indicate a bilateral procedure.
Physician Fee Schedule assigns a "1" bilateral indicator to both CPT codes 16641 and 76642 which means that Medicare
The Medicare
will allow 150
4
List separately in addition to code for pnmary procedure 77067.
5
List separately in 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
7
Codes 19081-19066 are to be used for breast biopsies that include image guidance, placement of localization device, and Imaging of
8
Codes 19281-19288 are for image guidance placement of localization device without image -guided biopsy
These codes
should not be
9
For CPT 10011 use the reimbursement rate for CPT code 10009. For CPT 10012 use the reimbursement rate for CPT code 10010.
10
NPV DNA testing Is not a reimbursable test for women under 30 years of age.
11
A LEEP orconization 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 Ionization of the cervix as a treatment procedure cannot be reimbursed by
12
Example: If procedure is 50 minutes. code 99156 + (99157 x 2). No separate charge allowed if procedure
13
These procedures have not been approved for coverage by Medicare. Please see code 77063 as the approved code for screening
14
The tamer specific
Medicare's methodology
pogoc 00 107,
Medicare anesthesia conversion rates are available here: Aneslheslctofllsts enter_
for the payment of anesthesia services are outlined in the Medicare Claims Processing Manual, Chapter 12,
available here http://www,cms.hhi.gov/mankials/downinadchmln4p12 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-I9 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 WWCICPED 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
12
Docusign Envelope ID: 7F7A4FDB-1166-4E65-8860-2C21B8E891BD
SCHEDULE B
SAMPLE VOUCHER
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
1555 North 17th Avenue, Greeley, CO 00631 www.weldheolth.or9
Radiology Service Voucher
'Ibis voucher is for the fitllowing patient who has been confirmed as eligible for.
E:rre rupdn es porn (nylrennrurx que son �nr)irmnrAr, efegiAle pmv
o Women's Wellness Conn.:Con Program n I H Program
Patient: Please present this voucher, as well as any other paperwork given to you, as you arrive dr your
radiology appointment to ensure proper billing. Your appointment is scheduled at:
filctwxidn WW1.kf .Su tiro er prrogmmrtdn en
Sawmill View Medical Cnnutooa
200170. Avenue, Greeley, CO 80634
(970) 810-6070
Appointment dalehime:
Fvchn dz (a . Na
Patient's name:
Nr ,Ere r(el pr. R n,a
o North Colorado Medical Center
1801 16. Street, Greeley, CO 80631
(970)810.4121
Patient's Date of Binh:
Covered service for lids visit:
Servido aaakrro pupa este au
*All other services will require prior authorization.
Today this sin... se requiems aurorhacldn prevla.
NOTE: This voucher egslres fill days alter dale of Issue.
Issue date: Authorized Signature:
Service Provider: nkaie hill Weld County IS an insurance for ihe'hove listed veMce only:
Weld County Department of Public Health
Attn: Contract Billing
1554 North 17th Avenue, Greeley, CO 80631
I ryou hate any q�estion>or nreJ ie rey:hedule, pleesr csll (97f1J i0d-6420.
5'i Dyredrimen(gr,na p.";;Iinnliensi(ue ratEIr ialto, l:rv%o,nrIfnme N't)1304642a
.card"1":whn rWlc M. Dthi
1914 4eab C4nkd4arbn
teb. 91D s1,M10
5911. 4112
1 *4:7Mal N.ah, C.nmWeabn.
1.Mc., Nyeaavn t /,om6p { Papaw
le�9l0.MNdr15 reb-4tD ,3atMT r�yy; pia y0, d1�0
Rc,ised IIf2016
12
Contract Form
Entity Information
Entity Name* Entity ID"
BANNER IMAGING SERVICES @00043542
COLORADO LLC
Q New Entity?
Contract Name* Contract ID
WOMEN'S WELLNESS CONNECTION DIAGNOSTIC 8970
SERVICES AGREEMENT - LOVELAND
Contract Status
CTB REVIEW
Contract Lead
BFRITZ
Contract Lead Email
bfritz@weld.gov;Health-
Contracts@weld.gov
Contract Description *
WOMEN'S WELLNESS CONNECTION DIAGNOSTIC SERVICES AGREEMENT
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-
DeptHead@weld.gov
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
Parent Contract ID
Requires Board Approval
YES
Department Project #
Requested BOCC Agenda Due Date
Date* 01 /02/2025
01/06/2025
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 *
11/01/2025
Committed Delivery Date
Renewal Date
Expiration Date*
12/31/2025
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
12/18/2024
Final Approval
BOCC Approved
BOCC Signed Date
BOCC Agenda Date
01/06/2025
Finance Approver
CHERYL PATTELLI
Legal Counsel
BYRON HOWELL
Finance Approved Date Legal Counsel Approved Date
12/18/2024 12/18/2024
Tyler Ref #
AG 010625
Originator
BFRITZ
Hello