2.11_Combined_A_121015.pdf

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 # L27375. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 18 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  BelowMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 291.06 291.06 291.06 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YMagnesium level (83735) Yes 194.04 194.04 194.04 0.00 X,YPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XPhosphate level (84100) Yes 72.77 72.77 72.77 0.00 XClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveXThis service is paid at 100% of the Medicare approved amount.YLocal 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 # L27375. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 19 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  BelowPhosphate level (84100) Yes 72.77 72.77 0.00 0.00 ZPhosphate level (84100) Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 218.31 218.31 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZPhosphate level (84100) Yes 145.54 145.54 0.00 0.00 ZUrine potassium level (84133) Yes 34.18 34.18 0.00 0.00 ZUrine potassium level (84133) Yes 34.18 34.18 0.00 0.00 ZUrine sodium level (84300) Yes 31.97 31.97 0.00 0.00 ZUrine sodium level (84300) Yes 31.97 31.97 0.00 0.00 ZUrine sodium level (84300) Yes 31.97 31.97 0.00 0.00 ZBlood test, thyroid stimulating hormone (TSH) (84443)Yes 153.80 153.80 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 183.02 183.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 183.02 183.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 ZTroponin (protein) analysis (84484) Yes 83.02 83.02 0.00 0.00 ZUrea nitrogen level to assess kidney function (84540)Yes 169.79 169.79 0.00 0.00 ZSyphilis detection test (86592) Yes 73.87 73.87 0.00 0.00 ZDetection test for Influenza virus, A or B (87400)Yes 140.76 140.76 0.00 0.00 ZClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveZThis 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 20 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  BelowComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 48.51 48.51 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85025)Yes 97.02 97.02 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 bComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 aComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 aClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveaThis service is paid at 100% of the Medicare approved amount.bThis item or service cannot be paid as billed.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 21 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  BelowComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 37.11 37.11 0.00 0.00 cComplete blood cell count (red cells, white blood