2.11_Combined_A_121015.pdf

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 cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 111.33 111.33 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 74.22 74.22 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 111.33 111.33 0.00 0.00 cComplete blood cell count (red cells, white blood cell, platelets), automated test (85027)Yes 111.33 111.33 0.00 0.00 cClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovecThis 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 22 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  BelowCoagulation function measurement (85379)Yes 136.71 136.71 0.00 0.00 dCoagulation function measurement (85379)Yes 136.71 136.71 0.00 0.00 dCoagulation function measurement (85379)Yes 136.71 136.71 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 44.10 44.10 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 88.20 88.20 0.00 0.00 dFibrinogen (Factor 1) antigen detection (85385)Yes 88.20 88.20 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 37.49 37.49 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dBlood test, clotting time (85610) Yes 74.98 74.98 0.00 0.00 dClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovedThis 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 23 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  BelowBacterial blood culture (87040) Yes 131.13 131.13 131.13 0.00 eBacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 fBacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 fBacterial blood culture (87040) Yes 232.26 232.26 232.26 0.00 fStool culture (87045) Yes 91.51 91.51 91.51 0.00 fBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 fBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 fBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 fBacterial culture and colony count for anaerobic bacteria (87073)Yes 121.25 121.25 121.25 0.00 fBacterial urine culture (87088) Yes 34.18 34.18 34.18 0.00 fBacterial urine culture (87088) Yes 34.18 34.18 34.18 0.00 fBacterial urine culture (87088) Yes 68.36 68.36 68.36 0.00 fFungal blood culture (mold or yeast) (87103)Yes 113.93 113.93 113.93 0.00 fSmear for parasites (87177) Yes 104.74 104.74 104.74 0.00 fImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 fImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 fDetection test for organism (87798) Yes 511.56 511.56 511.56 0.00 fDetection test for organism (87798) Yes 1,534.68 1,534.68 1,534.68 0.00 fSpecial stained specimen slides to identify organisms (88312)Yes 166.48 166.48 166.48 6.10Cell examination of specimen (88112)Yes 155.45 155.45 155.45 12.79Special stain for parasites (87209) Yes 69.46 69.46 69.46 0.00 fPathology examination of tissue using a microscope, moderately high complexity (88307)Yes 339.57 339.57 339.57 18.47Special stained specimen slides to identify organisms (88312)Yes 998.88 998.88 998.88 36.60Claim #21035000422104NYA (continued)Continued   Notes for Claims AboveeThis service is paid at 100% of the Medicare approved amount.fThis 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 24 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  BelowTissue or cell analysis by immunologic technique (88342)Yes 255.78 255.78 255.78 0.00 g,hXray of abdomen, single view (74000)Yes 213.06 213.06 213.06 10.55Xray of abdomen, single view (74000)Yes 213.06 213.06 213.06 10.55Xray of abdomen, single view (74000)Yes 213.06 213.06 213.06 10.55Xray of chest, 1 view, front (71010) Yes 667.01 667.01 667.01 21.09Xray of chest, 1 view, front (71010) Yes 1,124.55 1,124.55 1,124.55 31.64Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Xray of chest, 1 view, front (71010) Yes 374.85 374.85 374.85 10.55Total for Claim #21035000422104NYA $63,960.35 $63,960.35 $63,960.35 $234.64Notes for Claims AbovegMedicare cannot pay for this service for the diagnosis shown on the claim.hYou should not be billed for this service. You are only responsible for any deductible and coinsurance amounts listed in the Maximum You May Be Billed column.Continued   Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 25 of 26Your Home Health Claims for Part A