2.11_Combined_A_121015.pdf

(thyroid chemical) measurement (84439)Yes 151.04 151.04 151.04 0.00 GThyroid hormone, T3 measurement (84481)Yes 256.88 256.88 256.88 0.00 GClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveGThis 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 7 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Continued   Notes for Claims AboveHThis service is paid at 100% of the Medicare approved amount.Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowRed blood cell concentration measurement (85014)Yes 19.85 19.85 19.85 0.00 HRed blood cell concentration measurement (85014)Yes 59.55 59.55 59.55 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 59.55 59.55 59.55 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HHemoglobin measurement (85018) Yes 12.78 12.78 12.78 0.00 HHemoglobin measurement (85018) Yes 38.34 38.34 38.34 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 38.34 38.34 38.34 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHeparin assay (85520) Yes 1,188.50 1,188.50 1,188.50 0.00 HCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 HCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 HCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 HClaim #21035000422104NYA (continued)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...Continued   Notes for Claims AboveIThis service is paid at 100% of the Medicare approved amount.Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 IBlood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Claim #21035000422104NYA (continued)Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 9 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 group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Stool culture (87046) Yes 50.72 50.72 50.72 0.00 JBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 JScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 JScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 KScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 JScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 62.84 62.84 62.84 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 62.84 62.84 62.84 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 62.84 62.84 62.84 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 125.68 125.68 125.68 0.00 JSpecial stain for microorganism (87205)Yes 88.20 88.20 88.20 0.00 JSpecial stain for microorganism (87205)Yes 264.60 264.60 264.60 0.00 JSpecial stain for microorganism (87205)Yes 176.40 176.40 176.40 0.00 JSpecial stain for microorganism (87205)Yes 176.40 176.40 176.40 0.00 JClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveJThis service is paid at 100% of the Medicare approved amount.KThis 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 10 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeItem Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowSpecial stain for microorganism (87205)Yes 352.80 352.80 352.80 0.00 LTissue culture innoculation for virus isolation (87252)Yes 243.65 243.65 243.65 0.00 LDetection test for Adenovirus (virus) (87260)Yes 39.69 39.69 39.69 0.00 LDetection test for Parainfluenza virus (87279)Yes 119.07 119.07 119.07 0.00 LDetection test for Varicella (chicken pox) zoster virus (87290)Yes 70.38 70.38 70.38 0.00 LImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 LImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 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 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,