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Home My WebLink About20172020RESOLUTION RE: APPROVE THIRD AMENDMENT TO DIAGNOSTIC SERVICES AGREEMENT FOR WOMEN'S WELLNESS CONNECTION PROGRAM AND AUTHORIZE CHAIR TO SIGN - BANNER HEALTH, DBA 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 the Third Amendment to the Diagnostic Services Agreement for the Woman'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 Weld County Department of Public Health and Environment, and Banner Health, dba North Colorado Medical Center, commencing July 21, 2017, and ending July 20, 2018, 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 the Third Amendment to the Diagnostic Services Agreement for the Woman'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 Weld County Department of Public Health and Environment, and Banner Health, dba North Colorado Medical Center, 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 10th day of July, A.D., 2017. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLODO ATTEST:dj,,a e/ A) Weld County Clerk to the Board BYQ6,(2 ae.0 puty Clerk to the Board APPRO9ED AS T / County torney Date of signature: ' f (5 ( I Julie . Cozad, Chair Steve Moreno, PrQhem can P. Conway arbara Kirkmeyer cc. KLCST/T�/mw) ti7I17 2017-2020 HL0048 tb 4/235 Memorandum TO: Julie A. Cozad, Chair Board of County Commissioners FROM: Mark E. Wallace, MD, MPH Executive Director Department of Public Health & Environment DATE: July 5, 2017 SUBJECT: Banner -North Colorado Medical Center Imaging Contracts for Diagnostic Imaging/Radiology Enclosed for the Board's approval are two contracts between Banner Health/North Colorado Medical Center (Banner/NCMC) and the County of Weld, by and through the Board of Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment (WCDPHE). The Health Department is requesting approval to continue two separate contracts with Banner/NCMC to provide the technical component of diagnostic imaging/radiology services (the taking of x-rays) to designated eligible patients referred to Banner/NCMC by the Health Department. Specific services will include mammograms, ultrasounds, and two -view chest x-rays and will cover patients in the Tuberculosis Control and Women's Wellness Connection programs. Each one-year continuation contract has a new term of July 21, 2017, through July 20, 2018, and upon mutual written agreement may be extended for additional one year terms. Both contracts were approved for placement on the Board's agenda via pass -around memo dated June 30, 2017. I recommend approval of these two imaging contracts with Banner Health. 2017-2020 (-AL OO(4 'a DocuSlgn Envelope ID: 80E7BCE2-CF37-4938-8BB3-DE8375B77828 THIRD AMENDMENT TO DIAGNOSTIC SERVICES AGREEMENT (BH Contract Number 0314-03-43836 A3) THIS THIRD AMENDMENT TO DIAGNOSTIC SERVICES AGREEMENT ("Third Amendment") is made and entered into as of the signature dates set forth below, to be effective as of July 21, 2017 ("Effective Date") by and between Banner Health, an Arizona nonprofit corporation, d/b/a North Colorado Medical Center ("Banner") and the County of Weld, State al Colorado, by and through the Board of Commleskiners of Weld County, on behalf of the Weld County Department of Public Health and Environment ("WCDPHE"). Banner and WCDPHE may collectively be referred to as the Parties. RECITALS: A. Banner and WCDPHE are parties to that certain Agreement dated July 21, 2014, as amended from time to time (as amended, the "Agreement"), wherein Banner provides diagnostic/imaging radiology services to patients qualified for certain health services programs ("Designated Patients") through WCDPHE, as more particularly described therein. B. The Parties desire to extend the term of the Agreement. G The Parties desire to evidence this modification to the Agreement by execution of this Third Amendment. NOW THEREFORE, the Parties agree as set forth below: 1. Amendment of Agreement. Section 3 (Term and Termination) of the Agreement is hereby amended to extend the term of the Agreement for a period of one (1) year as of the Effective Date above and continuing through July 20, 2018, subject to earlier termination as provided in Section 3 of the Agreement. 2. Agreement Effective. Except as amended by this Third Amendment, the Agreement attached hereto and hereby made a part of this Third Amendment shall remain in full force and effect. 3. Precedence a Amendment. In the event of a conflict between the terms and conditions of this Third Amendment and the terms and conditions of the Agreement, the terms and conditions of this Third Amendment shall govern and control. 4. Capitalized Terms. All capitalized terms used in this Third Amendment and not otherwise defined herein shall have the meaning ascribed to such terms in the Agreement. 5. Incorporation. This Third Amendment shall be attached to, and made a part of, the Agreement. This Third Amendment will not be in effect until signed by both Parties. Banner Health, an Arizona nonprofit corporation, d/b/a North Colorado Med"• Cen By: ':...� .. argo Karsten •' Ch- Signature Date : SVW June2011 0314-03-43836 A3 r- 4 .2a% Well County Department of Public Health and Environment, by and through the Weld County Board of Commissioners Its: Chair, County Cssioners Signature Date : July 10, 2017 , of_1-DO@o 0 O V -C U d0 L C U O = a) vI c w •— • o 3 Qczs 3 O cG c -c c w o g vp cG U LI UU ti z L H w W Q .. � w cn- 3 z w W E U c)H E'L) < z 23 H w_ a U w ..c L.L. Z Ce c ct o tnoz a)4 - L Z p H pw ' v cu W 0 U L 'O a% 2U o �° a> > �i'Zaa.. a <U�p a4° al 0- U Z U L CA QCA CA Q a >-'W W U I) Z J U c a) w > t 0 3w o03 U CC4 as o w z _ i = - w w m O C° o 3 ¢ a.) c p ,O -o 3 z � "CS - o s- `,-• n. W O - L c4 'v c Ct C.) CA O � CL O 11 U ct o L schedule/overview.as OFFICE VISITS END NOTES — END NOTES -- — 00 0o 00 00 00 00 CT CT CT CT New Patient; detailed history, exam, straightforward decision -making; 30 minutes New Patient; comprehensive history, exam, moderate complexity decision -making; 45 minutes Established Patient; detailed history, exam, moderately complex decision -making; 25 minutes Established Patient; expanded history, exam, straightforward decision -making; 15 minutes BREAST SCREENING AND DIAGNOSTIC SERVICES Radiological examination, surgical specimen Ultrasound, complete examination of breast including axilla, unilateral Ultrasound, limited examination of breast including axilla, unilateral Ultrasonic guidance for needle placement, imaging supervision and interpretation Puncture aspiration of cyst of breast Puncture aspiration of cyst of breast, each additional cyst, used with 19000 Breast biopsy, percutaneous, needle core, not using imaging guidance Excision of cyst, fibroadenoma or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion; open; one or more lesions Excision of breast lesion identified by preoperative placement of radiological marker; open; single lesion Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotactic guidance; first lesion Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; stereotactic guidance; each additional lesion Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasound guidance; first lesion Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; ultrasound guidance; each additional lesion Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonance guidance; first lesion Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous; magnetic resonance guidance; each additional lesion Placement of breast localization device, percutaneous; mammographic guidance; first lesion Placement of breast localization device, percutaneous; mammographic guidance; each additional lesion Placement of breast localization device, percutaneous; stereotactic guidance; first lesion 19284 I Placement of breast localization device, percutaneous; stereotactic guidance; each additional lesion w E— A is, C") 0 99203 99204 99214 99213 CPT CODE 00 CT O 76641 76642 76942 O— O 0 a O 0 CT O— O -- as O ^-'—' O O N O, V7 N -- CT vO N — CT r- 00 0 CT N 00 0 CT M 00 0 CT 7 00 0 CT 00 0 CT \O 00 0 CT ,--• 00 N CT N 00 N CT M 00 N CT C' C` C` C` N N N Z F W 0 C O a 4Lc ai U C CC C 00 C C C O C C Ci C O a) C aC+ a a a) a ai a) C 0 C N C O C a) O C a) E a) C C O a) C C O C C a) a) U C C C Oo C 7 O C CM C O a) C a a) a) a ai U > 0 'C a 0 C N C U O CM C L o. O C a) E a) C C O a) ai U C CC a E a) C C O a) U U C E C O a) C C a) a) C ai U .> a) b C 0 C N C U O CM C a) O C a) E a) C C. C O a) C C O -a C s C a) aS U C C b E a) U C a C O a) U .0 C a O a) C a a) a ai U a) C 0 C N C O C a) 4-. O C a) E a) C C. a) U C cC 'C C bf) 00 a .5 C 0 .3 C O C C U a) a C 0 C LL U U a C :a C 00 00 C C S C O C a a) a) a) C a) C Lc. CM C U E a) U a O as' C N a) a E L a) U 0 C a a) OO O O CM 0 U a) -C a) E S a) C a a) a) c a) C C 0 C 0 C C CC a) T 00 O 0 t C a 0 T U aO Obi C) O • • v b a) a) a CC a) 013 C O C C S CC N U E. O C) CM O a) E tic CM O 00 00 O O C a C U C ti C OO C E CC U OO C CM 0 C O C a C > a) a) 'a 0 U O U E 00 C .C L a O C C E C� N a) U a O U 2 O U S C C CM O 00 00 O O C a C U 00 C C a) ctEi Tat 00 E C 00 O E E cC 00 C C a) a) U C C OO Ca E C 01 O E E C 0 C C Tat N (15 C .00 E C 00 O E E C 0 C C I I C a) C CC a) CC U a) a) a) w a) a) a a a) 0 0 C CC L O L Y C C E U C N E a OO a) C C 0 CM C 'C a) U O L a L C a N C U C To CM C 00 O C 00 5O E C 500 O U a 'C cC E E C O a. C. LL C: C. Lt] ice LLa ce a.) a) C C C C C O U C O C C C C a) an C C E a) U C C C O CM a) U a) C 00 C > 0 C; C. C, LU C. Li] a4 LU oC C a) C C C O U C O L 0 'C _O C (I) .a 00 C C E a) U C a C O a) Ca! U a) C C 0 U CM a) C U C C i C C a T 00 O cow E C 0 C 0 0 U CM .0 C .E L a) C C. 00 O E CC 2 0 C C 0 C 6 a) U O a U .OO C a) C C cat a) w > CC a) a) C T U E a) C O t C 'C a) U 0 a. a) (L) 4) CM a) T U C C C 00 a) C. T • C E C U C.) 00 C a) a) L a) a O 6' SERVICES NG AND DIAGN©S CERVICAL SC 00 C .C a) a) C C C E E a) CM T CC CM a) a) .C 0 O a a) C C cat O CC a) e. a) U A a) a C C. • a O O . a) L O V CM T cCC o O >, .C a a. aa)) T U � C C U • a a) C C 00 C .C a) a) L U a .a C 00 C .C a) a) U C C CC E E a) T C a) a) ._ 'C a) O a a) C C C > O U L a) U a C C. C a O C C O U T. O .0• •o O a >, U CM a) "C C 00 C C a) a) U CM C C C C E C O C a a) a a) C C s-+ 0 C E 0 C b E a) C a) a) a)C C U O U cC C C > 0 C L a) U CM a) a C a. a) C C O . - L o C. O CM C a U O T U a 00 C C a) cat CM C C as E C O C C a a) a a) C C 0 a) a) C E O C C b C a) > C L a) a) a C -c a U •0 • L U N a C O •a > .� L y O >` • a U N (i) U C 00 Oo _C as O U co C cC U CM T a N C C C )E () 'C a) C� E O C co T 00 C 0 a) L U C O L cC a a) a C C C b C E O C C C Ir.. a) > C L a) I- a C a) a) N O C C > O cC N U 000 O o C • > a) o a U CM C C aJ cC E C E a) C E O C C T 00 C C U L CM O C C a a) a C C a) a) C E O C cC d C a) > L a) a`i a C 'a N U N C • 0 ._ L C a a. O — •CM U T L a) U TS j, bq C O oo E Q L T CM U CM a) a T s 00 cat Z CM C > C E O C. C E C 2 C 0 00 0 C CA a C > CC E O C C. C E C x N L` a) C a) C U U > a) U O 0 a C C T C a O -C N > a) U a) O CT. O U CM 0 a. O U CM a 0 N a) U a) O T a O U O a_ O U a) 0 a) C U cc; a) U 0 a a a) 3 N > a) U a) 4. O T a 0 U CM 0 a O U a a. C. c/] O T a) a) C 0 a C C 0 a a cC a) 4 U a) L C a' a) N L a) U a) t O CM C a O a) 'a 0 U U U a O O T a O U O a O U 00 N C` 00 00 N C' N 00 N C' 00 00 N C` N N N N N 00 00 t\ 00 00 00 oo 00 00 00 N N U N C, CD O N V 00 N C, N r` N C O C 00 00 00 00 00 00 N 00 00 00 00 N 00 00 N 00 00 N 00 00 N N 00 N 1` 1` N 1` 1` S CLINICAL SERVICES AND PROCEDURES SPECIFICALLY NOT ALLOWED All consultations should be billed through the standard "new patient" office visit CPT codes 99203 or 99204. Consultations billed as 99204 must meet the CPT coding guidelines for this code. CPT code 99204 is not appropriate for WWC screening visits. I'he type and duration of office visits should be appropriate to the level of care necessary for accomplishing screening and diagnostic follow-up. Reimbursement rates should not exceed those published by Medicare. While the use of 993XX-series codes may be necessary in some programs, the 993XX Preventive Medicine Evaluation visits themselves are not appropriate for WWC programs. 9938X codes shall be reimbursed at or below the 99203 rate, and 9939X codes shall be reimbursed at or below the 99213 rate. 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.cms.hhs.gov/manuals/downloads/clm104c12.pdf This charge should be used with caution to ensure programs do not reimburse for supplies, the cost of which, has already been accounted for in another clinical charge. Breast MRI can be reimbursed 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 5 risk of 20-25% or greater as defined by risk assessment models such as BRCAPRO that are largely dependent on family history. Breast MRI can also be used to better assess areas of concern on a mammogram or for evaluation of a client with a past history of breast cancer after completing treatment. Breast MRI should never be Colposcopy with loop electrode conization of the cervix Requires WWC Preapproval unless done after HSIL or AIS Pap test. Cervical biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) Use this code for cervical polyp removal Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser Loop electrode excision procedure Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure). Only for diagnostic purposes following AGC Pap. Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary procedure). Only for diagnostic purposes following AGC Pap. Surgical pathology, gross and microscopic examination Pathology consultation during surgery, first tissue block, with frozen section(s). single specimen Pathology consultation during surgery, each additional tissue block, with frozen section(s) Immunohistochemistry antibody slide Immunohistochemistry antibody slide 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) Pre -operative testing; CBC, urinalysis, pregnancy test, etc. These procedures should be medically necessary for the planned surgical procedure. Treatment of breast cancer, cervical intraepithelial neoplasia and cervical cancer. Breast tomosynthesis, unilateral/bilateral. Human Papillomavirus, low -risk types w U a w un At U z a U U a at r) 3 a w v) w U Q C C O z T) et 4. O i. cC L1. cn cd a) a O 'G O a a) 00 cri N L U ct U s.. G) U 0 'O C LC) ,O 57500 57505 57520 57522 O O 88305 Mc,') V i 99070 IVarious CPT CODES T ,.CD- r- rn N M M M M C _c -c O O O C N �p L- In 00 An 00 Vl 00 00 00 00 00 00 00 00 Q' r r- r cC V n 00 '� N M 7' Fvhihit A performed alone as a breast cancer screening tool. Breast MRI cannot be reimbursed to assess the extent of disease in a woman who has just been diagnosed with breast cancer. 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. 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. These procedures may be reimbursed at their own Medicare rates. They no longer have to be reimbursed at the 88142 rate. For a bilateral breast ultrasound, a modifier 50 should be added to either 76641 or 76642 to indicate a bilateral procedure. The Medicare Physician Fee Schedule assigns a "I" bilateral indicator to both CPT codes 76641 and 76642 which means that Medicare will allow 150 percent of the standard reimbursement rate. There should not be two CPT codes billed if a bilateral ultrasound exam is needed. 10 Due to Medicare claims processing issues, CMS will not be able to process the new mammography codes. Therefore no reimbursement fees have been assigned to these codes. Use only G0202, G0204, and G0206 until this has been resolved. c N. 0O CI, er eP v O. 0. DocuSign Envelope ID: DC15F30E-2281-44CB-961E-A65FC631DA9A WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 North 17th Avenue, Greeley, CO 80631 www.weldhealth.orq EXHIBIT B Radiology Service Voucher This voucher is for the following patient who has been confirmed as eligible for: Este cupon es porn las personas qua son cantirmadas elegible para: Women's Wellness Connection Program TB Program ZIKA OB Ultrasound 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 Ilegar a su cita par favor presente este capon v otros documentos necesarios entregados a usted, para asegurar let facturacion apropiada. Su city es programada en: Summit View Medical Commons 2001 70th Avenue, Greeley, CO 80634 (970) 810-6070 North Colorado Medical Center 1801 16th Street, Greeley, CO 80631 (970) 810-4121 Appointment date/time: Patient's Date of Birth: Fecha de la city Fecha de nucimiento Patient's name: _ Nomnbre del paciente Covered service for this visit: Servicio cubierto pant estu cite *AII other services will require prior authorization. Todos otros servicios se requieren autorizucion 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 tlane alguna pregunta o tiene qua cancelar la vita, por favor llama (970) 304-6420. Health Administration Vital Records r .'04 s4!; Public Health & Clinical Services ei., Environmental HeaRh Communication. Services Education & Planning F, <: •') i4 Emergency Preparedness & Response Public Health Revised I I /2016 Hello