1. Contract Language for Family Planning Services Cost Center 802 Debra Israel Director Family Planning Program Division of Women’s Health Department for Public Health 1

2. Three types of contacts allowed for Title X funds in the KY Family Planning Program 1.Personnel contracts for onsite APRN/MD for family planning clinical services 2.Referrals to midlevel clinician or higher to insert methods not provided on site or perform sterilization procedures 3.Outpatient surgery center or hospital for pre-op, OR, and post-op care for tubal sterilization 2

3. Personnel Contracts for APRN/MD for on site family planning clinical services Must include: provider credentials, scope of services, hours of work, payment rate Must adhere to: FP guidelines, PHPR, AR, Vol. 1 Program Guidelines, Family Planning LHD shall bill for services provided by contracted onsite providers Identify: who will carry professional liability (i.e. the contractor or the LHD) 3

4. Referring contract MD/APRN for sterilization procedure, IUD and/or Implanon Contractor must bill the LHD directly for services for self pay patients, uninsured or underinsured** Contractor shall bill Third Party Payers **Underinsured: For patients <250% federal poverty level, if insurance coverage includes high deductable or percent of pay and presents a barrier for the patient, the patient fee shall be based on the federal sliding fee schedule for self pay. 4

5. Referring contract MD/APRN for sterilization, IUD and/or Implanon Contract fees should align with current Medicaid rates: DMS Physician fee rates can be found at the following CHFS/DMS link: http://chfs.ky.gov/dms/fee.htm under “Physician Fee Service”. Open PDF version and enter the CPT code in the FIND box to locate the fee easily. http://chfs.ky.gov/dms/fee.htm Contractor certifies that it carries professional liability insurance Medical record for services rendered shall be forwarded to HD prior to payment 5

6. Referring contract MD/APRN for Sterilization Federal sterilization consent form shall be signed in the HD or the MD office Appropriate counseling will be done by LHD staff when consent form is signed Order copies or download federal sterilization consent form and patient education at Office of Population Affairs Clearinghouse http://www.opaclearinghouse.org/title.html. http://www.opaclearinghouse.org/title.html 6

7. Referring contract MD for Sterilizations 7 CPT CodeDescriptionDMS Physician Rate 58670Bilateral Laparoscopic Tubal Ligation w/Fulguration$280.12 58671Bilateral Laparoscopic Tubal Ligation w/Band, Clip, etc.$287.90 58605Bilateral Tubal Ligation Postpartum, Laparotomy$234.00 58611Bilateral Tubal Ligation at time of C-section$33.52 55250Vasectomy $ 171.54

8. Referring contract MD/APRN for IUD and/or Implanon Self Pay Patients: LHD shall provide IUD device for contracted MD/APRN to insert. Contractor shall bill only for insertion fee For Patients with 3 rd Party Payers: contractor shall provide the device and bill 3 rd party payers for device and insertion fee 8 CodeDescriptionDMS Physician Rate 58300IUD insertion $ 59.25 58301IUD removal $ 35.43 11975Insertion of Implantable Contraception$100.35 11976Removal of Implantable Contraception$93.85 11977Removal/Reinsert Implantable Contraception$184.89

9. NEW IMPLANON CODES!!! CodeDescriptionDMS Physician Rate 58300IUD insertion $59.25 58301IUD removal $35.43 11981 Insertion, non-biodegradable drug delivery implant $86.88 11982 Removal, non-biodegradable drug delivery implant $99.36 11983 Removal with reinsertion, non- biodegradable drug delivery implant $162.35 76857Limited Pelvic Ultrasound *** $44.96 9

10. Hospital out-patient services for voluntary sterilization procedures The contractor shall bill for services directly to the LHD for self pay patients, uninsured or underinsured. The contractor shall bill for services directly to Medicaid or private insurance, when the services are covered for reimbursement by a Third Party payer. Contract prices for services for uninsured clients shall be aligned with current Medicaid and DPH approved rates. Prior approval of the procedure must be obtained from the Health Department. The Contractor agrees to provide necessary pre op lab tests. 10

11. IUD If an ultrasound to check for IUD placement is medically necessary, use the code for a limited pelvic ultrasound. Clearly document on request purpose for IUD placement only: CPT Code 76857ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE $44.96 REMEMBER it is best to check IUD strings at end of menstrual cycle!! 11

12. Hospital out-patient services for voluntary sterilization procedures, cont’d The patient must have a negative pregnancy test prior to the procedure being performed. The Contractor agrees to conduct counseling to patient regarding the elective sterilization procedure The Contractor agrees to accept the signed consent form. The federal sterilization consent form must be signed in the health department at least thirty (30) days (no less) prior to the date of surgery and the procedure performed within 180 day of the signature. A copy of the consent must be filed in the patient’s LHD medical record. 12

13. Hospital out-patient services for voluntary sterilization procedures, cont’d 13 The medical record for the service rendered shall be forwarded to the HD prior to payment to Contractor. The Contractor certifies that it carries its own professional liability insurance. *The Anesthesia Base Rate is $15.20. Each 15 minute increment=1 time unit. CodeDescriptionDMS/DPH Rate W0166Hospital Pre/OR/Post op$800 00851Anesthesia for Tubal Ligation/transaction6 units max* 00921 Anesthesia for Vasectomy 3 units max*

14. IMPORTANT What internal processes do you have for processing invoices from contractors??? How do you assure the correct procedure or service requested by the LHD is being billed? Does contractor send an invoice with their FULL RATE charge on bill? Does the staff paying the invoice know the contracted rate for the procedure or service to assure YOU do not pay TOO MUCH? 14

15. THANK YOU Questions?? Debra Israel, 502-564-3236 ext. 4590 debra.israel@ky.govdebra.israel@ky.gov Emily Adkins, 502-564-3236 ext. 3822 emily.adkins@ky.govemily.adkins@ky.gov 15