2.11_Combined_A_121015.pdf

574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveLThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 11 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 MBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 MBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 MBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 MBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 MBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 MClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveMThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 12 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NAlcohol (ethanol) level (82055) Yes 116.87 116.87 116.87 0.00 NAmmonia level (82140) Yes 72.77 72.77 72.77 0.00 NAmmonia level (82140) Yes 72.77 72.77 72.77 0.00 NAmylase (enzyme) level (82150) Yes 51.82 51.82 51.82 0.00 NCalcium level (82330) Yes 193.05 193.05 193.05 0.00 N,OCalcium level (82330) Yes 579.15 579.15 579.15 0.00 N,OCalcium level (82330) Yes 386.10 386.10 386.10 0.00 N,OClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveNThis service is paid at 100% of the Medicare approved amount.OLocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD # L28209. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 13 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 579.15 579.15 579.15 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCyanocobalamin (vitamin B-12) level (82607)Yes 108.05 108.05 108.05 0.00 PCyanocobalamin (vitamin B-12) level (82607)Yes 108.05 108.05 108.05 0.00 PFolic acid level (82746) Yes 144.43 144.43 144.43 0.00 PFolic acid level (82746) Yes 144.43 144.43 144.43 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 28.00 28.00 28.00 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 28.00 28.00 28.00 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 196.00 196.00 196.00 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 PClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovePThis service is paid at 100% of the Medicare approved amount.PQLocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD # L28209. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer WashingtonOcboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 364.00 364.00 364.00 0.00 RBlood glucose