Kansas Department of Health and Environment: Early Detection Works Subcontractor Reimbursement Information Attachment B

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Reimbursement Information

Early Detection Works
Kansas Breast and Cervical Screening Program
Subcontractor Reimbursement Information
Attachment B

Please TAB through the form as information is entered. Use the ENTER button only to submit the completed form.

Subcontractor 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.:

Acting as a subcontractor for:

Although EDW will reimburse according to the Reimbursement Fee Schedule (Attachment C), for CDC reporting purposes we must know the subcontractor's customary charge for each of the following. If you will not provide that service for the above provider please indicate "n/a" in the appropriate blanks.

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
99214..... Established patient visit – 25 minutes face-to-face
99241..... Consultation – 15 minutes face-to-face
99242..... Consultation – 30 minutes face-to-face
99243..... Consultation – 45 minutes face-to-face

Breast

77057..... Screening Mammogram
77057TC..... .....Technical Component
77057PC..... .....Professional Component
77055..... Diagnostic Unilateral Mammogram
77055TC..... .....Technical Component
77055PC..... .....Professional Component
77056..... Diagnostic Bilateral Mammogram
77056TC..... .....Technical Component
77056PC..... .....Professional Component
76645..... Diagnostic Ultrasound
76645TC..... .....Technical Component
76645PC..... .....Professional Component

Fine Needle Aspiration

10021..... Fine Needle Aspiration without imaging guidance
10022..... Fine Needle Aspiration with imaging guidance
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

Excisional Biopsy

19100..... Needle Core Biopsy, not using imaging guidance
19100FF..... .....Facility Fee
19101..... Open, Incisional Biopsy
19101FF..... .....Facility Fee
19102..... Precutaneous, needle core, using imaging guidance
19102FF..... .....Facility Fee
19103..... Precutaneous, needle core, auto vacuum-assisted or rotating biopsy device
19103FF..... .....Facility Fee
19120..... Excision of Cyst
19120FF..... .....Facility Fee
19125..... Excision of Breast Lesion, single
19125FF..... .....Facility Fee
19126..... Excision of Breast Lesion, each add'l. lesion separately identified
19290..... Preoperative placement of needle localization wire
19291..... Preoperative placement of needle localization wire, each add'l. lesion
19295..... Image guided placement, metallic localization clip

Incisional Biopsy

19000..... Puncture aspiration of cyst of breast
19001..... Puncture aspiration of cyst of breast, each add'l cyst

Radiology

77031..... Stereotactic localization guidance for breast bx/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..... Breast 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 Smear
88142..... Pap test, liquid-based
88141..... Cytopathology, cervical or vaginal, interpretation by physician
87621..... Lab, HPV, amplified probe technique
57452..... Colposcopy without biopsy
57454..... Colposcopy with biopsy & endocervical curettage
57455..... Colposcopy with biopsy
57456..... Colposcopy with biopsy with endocervical curettage
57460..... Colposcopy of the cervix w/loop electrode biopsy(s) of the cervix
57461..... Colposcopy of the cervix w/loop electrode conization of the cervix
57500..... Biopsy, single or multiple or local excision of lesion with or without fulgaration
57505..... Endocervical curettage (not done as part of a dilation and curettage)
57520..... Conization of cervix
57520FF..... .....Facility Fee
57522..... Loop electrode excision
57522FF..... .....Facility Fee
58100..... Endometrial sampling with or w/o endocervical sampling, w/o cervical dilation
88305..... Cervical Biopsy Interpretation
88305TC..... .....Technical Component
88305PC..... .....Professional Component

Anesthesia

ANESTH..... General Anesthesia

Early Detection Works Kansas Breast and Cervical Screening Program Subcontractor Reimbursement Information Attachment B