calculate rates for CBEs, biopsies, surgical consults

A question was asked about calculating Komen rates for CBEs, biopsies & surgical consults.

Komen allows 50% of the office visit rate for CBEs, assuming that health issues not related to breast cancer/breast health will be covered during the office visit. For the 2016 grant cycle, the Komen-allowed CBE rate would be 50% for codes 99203 or 99204 (new patients) or 99213, 99214 (established patients). It would be acceptable to average the two rates & then halve that average – so long as you explain that in your budget justification.

We will accept an average of biopsy rates for codes 19100-19101, 19081-19086, & 19281-19288, with any code combinations you’ve seen for localization devices, image guidance, etc. that are in line with the notes 8 & 9 on the WWC rate sheet (Attachment B in the RFA documents).

Komen Colorado aims to reimburse at the same rates as WWC to ensure Komen-funded patients are treated no less favorably due to reimburseable rates, so if you have surgical consult or biopsy rates from WWC, including those rates & where you got them from would be sufficient for determining compliance for the Komen applications.