Reimbursement Information

Early Detection Works (EDW)
Kansas Breast and Cervical Screening Program
Attachment B

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Contracting Agency Name:

Address: (Line 1 - Put your Building or Suite and Street Address here.)

Address: (Line 2 - Put your City , State, Zip Code information here.)

County:

Contact Person:

Phone Number:

Fax Number:

Email:

Federal Employer ID No.:

Although EDW will reimburse providers according to the Reimbursement Fee Schedule (Attachment C), for CDC reporting purposes we must know your customary charge for each of the following.

Office Visits

99201..... New patient visit – 10 minutes face-to-face
99202..... New patient visit – 20 minutes face-to-face
99203..... New patient visit – 30 minutes face-to-face
99211..... Established patient visit – 5 minutes face-to-face
99212..... Established patient visit – 10 minutes face-to-face
99213..... Established patient visit – 15 minutes face-to-face
Breast
77057..... Screening Mammogram, film
77057TC..... .....Technical Component
77057PC..... .....Professional Component
77056..... Diagnostic Bilateral Mammogram, film
77056TC..... .....Technical Component
77056PC..... .....Professional Component
77055..... Diagnostic Unilateral Mammogram, film
77055TC..... .....Technical Component
77055PC..... .....Professional Component
G0202..... Screening Mammogram, digital
G0202TC..... .....Technical Component
G0202PC..... .....Professional Component
G0204..... Diagnostic Bilateral Mammogram, digital
G0204TC..... .....Technical Component
G0204PC..... .....Professional Component
G0206..... Diagnostic Unilateral Mammogram, digital
G0206TC..... .....Technical Component
G0206PC..... .....Professional Component
76645..... Diagnostic Ultrasound
76645TC..... .....Technical Component
76645PC..... .....Professional Component
Fine Needle Aspiration
10021..... Fine Needle Aspiration without imaging guidance (performed in office)
10021..... Fine Needle Aspiration without imaging guidance (performed in facility)
10021ff..... .....Facility Fee
10022..... Fine Needle Aspiration with imaging guidance (performed in office)
10022..... Fine Needle Aspiration with imaging guidance (performed in facility)
10022ff..... .....Facility Fee
88172..... Cytopathology, evaluation of fine needle aspirate
88172TC..... .....Technical Component
88172PC..... .....Professional Component
88173..... Interpretation of Fine Needle Aspiration
88173TC..... .....Technical Component
88173PC..... .....Professional Component
Incisional Biopsy
19000..... Puncture aspiration of cyst of breast (performed in office)
19000..... Puncture aspiration of cyst of breast (performed in facility)
19000ff..... .....Facility Fee
19001..... Puncture aspiration of cyst of breast, each add'l cyst (performed in office)
19001..... Puncture aspiration of cyst of breast, each add'l cyst (performed in facility)
19001ff..... .....Facility Fee
Excisional Biopsy
19100..... Needle Core Biopsy, not using imaging guidance (performed in office)
19100..... Needle Core Biopsy, not using imaging guidance (performed in facility)
19100FF..... .....Facility Fee
19101..... Open, Incisional Biopsy (performed in office)
19101..... Open, Incisional Biopsy (performed in facility)
19101FF..... .....Facility Fee
19102..... Prec., needle core, using imaging guidance (performed in office)
19102..... Prec., needle core, using imaging guidance (performed in facility)
19102FF..... .....Facility Fee
19103..... Prec., needle core, auto vac-assisted or rotating biopsy device (performed in office)
19103..... Prec., needle core, auto vac-assisted or rotating biopsy device (performed in facility)
19103FF..... .....Facility Fee
19120..... Excision of Cyst (performed in office)
19120..... Excision of Cyst (performed in facility)
19120FF..... .....Facility Fee
19125..... Excision of Breast Lesion, single (performed in office)
19125..... Excision of Breast Lesion, single (performed in facility)
19125FF..... .....Facility Fee
19126..... Excision of Breast Lesion, each add'l. lesion separately identified
19290..... Preoperative placement of needle localization wire (performed in office)
19290..... Preoperative placement of needle localization wire (performed in facility)
19291..... Preoperative placement of needle localization wire, each add'l. lesion
19295..... Image guided placement, metallic localization clip
Radiology
77031..... Stereotactic localization guidance for breast biopsy/needle placement
77031TC..... .....Technical Component
77031PC..... .....Professional Component
77032..... Preoperative placement of needle localization wire (radiological)
77032TC..... .....Technical Component
77032PC..... .....Professional Component
76098..... Radiological Examination, surgical specimen
76098TC..... .....Technical Component
76098PC..... .....Professional Component
76942..... Ultrasonic guidance for needle placement
76942TC..... .....Technical Component
76942PC..... .....Professional Component
Lab and Pathology
88305..... Biopsy Interpretation
88305TC..... .....Technical Component
88305PC..... .....Professional Component
88307..... Surgical Pathology, gross & microscopic exam requiring eval of surg. margins
88307TC..... .....Technical Component
88307PC..... .....Professional Component
88331..... First tissue block, with frozen section(s), single specimen
88331TC..... .....Technical Component
88331PC..... .....Professional Component
88332..... Surgical Pathology, gross & micro exam requiring eval of surg. margins
88332TC..... .....Technical Component
88332PC..... .....Professional Component
Cervical
88164..... Pap test
88142..... Pap test, liquid-based
88143..... Pap test, liquid-based
88174..... Pap test, liquid-based
88175..... Pap test, liquid-based
88141..... Cytopathology, cervical or vaginal, interpretation by physician
87621..... Lab, HPV, amplified probe technique
57452..... Colposcopy without biopsy (performed in office)
57452..... Colposcopy without biopsy (performed in facility)
57452FF..... .....Facility Fee
57454..... Colposcopy with biopsy & endocervical curettage (performed in office)
57454..... Colposcopy with biopsy & endocervical curettage (performed in facility)
57454FF..... .....Facility Fee
57455..... Colposcopy with biopsy (performed in office)
57455..... Colposcopy with biopsy (performed in facility)
57455FF..... .....Facility Fee
57456..... Colposcopy with biopsy with endocervical curettage (performed in office)
57456..... Colposcopy with biopsy with endocervical curettage (performed in facility)
57456FF..... .....Facility Fee
57460..... Colposcopy of the cervix w/loop electrode biopsy(s) of the cervix (performed in office)
57460..... Colposcopy of the cervix w/loop electrode biopsy(s) of the cervix (performed in facility)
57460FF..... .....Facility Fee
57461..... Colpo of the cervix w/loop electrode conization of the cervix (performed in office)
57461..... Colpo of the cervix w/loop electrode conization of the cervix (performed in facility)
57461FF..... .....Facility Fee
57500..... Biopsy, single/mult or local exc of lesion with/without fulgaration (performed in office)
57500..... Biopsy, single/mult or local exc of lesion with/without fulgaration (performed in facility)
57500FF..... .....Facility Fee
57505..... Endocervical curettage (not as part of a dilation and curettage) (performed in office)
57505..... Endocervical curettage (not as part of a dilation and curettage) (performed in facility)
57505FF..... .....Facility Fee
57520..... Conization of cervix (performed in office)
57520..... Conization of cervix (performed in facility)
57520FF..... .....Facility Fee
57522..... Loop electrode excision (performed in office)
57522..... Loop electrode excision (performed in facility)
57522FF..... .....Facility Fee
58100..... Endometrial sampling with or w/o endocerv sampling, w/o cerv dilation (performed in office)
58100..... Endometrial sampling with or w/o endocerv sampling, w/o cerv dilation (performed in facility)
58100FF..... .....Facility Fee
Anesthesia
ANESTH..... General Anesthesia