Question: U33 fx D E F G H 223 B 1 Assumption ED Visit 2- MCR CCR 0.227 3 WI 0.8934 4 DOS 2018 5 DX

U33 fx D E F G H 223 B 1 Assumption ED Visit 2- MCR CCR 0.227 3 WI 0.8934 4 DOS 2018 5 DX S61.409A 6 7 8 Claim Information 9 RC CPT 10 361 29130 11 450 99285 12 363 90714 13 940 90471 14 15 16 17 18 Medicare Payment Mod-1 Mod-2 25 Unit 1 $ 1 S 1 $ 1 S TOTAL Charge $ Cost $ Charge 157.50 654,42 140.60 29.99 982.51 223.03 $ 157.50 $ 654.42 $ 140.60 $ 29,99 Total Charge $ 982.51 X MCR CCR x 0.227 Cost S 223.03 Wi adjusted Payment SI N & NON 19 20 21 22 23 24 25 26 27 RC 361 450 363 940 CPT 29130 99285 90714 90471 APC 0000 5023 0000 0000 472.24 (504.51 x 60 x 0.8934) + (504,51 x.40) = 472.24 ZZZ Unadjusted Payment $ S 504,51 $ $ S N Total Reimbursement Profit or Loss? U33 fx D E F G H 223 B 1 Assumption ED Visit 2- MCR CCR 0.227 3 WI 0.8934 4 DOS 2018 5 DX S61.409A 6 7 8 Claim Information 9 RC CPT 10 361 29130 11 450 99285 12 363 90714 13 940 90471 14 15 16 17 18 Medicare Payment Mod-1 Mod-2 25 Unit 1 $ 1 S 1 $ 1 S TOTAL Charge $ Cost $ Charge 157.50 654,42 140.60 29.99 982.51 223.03 $ 157.50 $ 654.42 $ 140.60 $ 29,99 Total Charge $ 982.51 X MCR CCR x 0.227 Cost S 223.03 Wi adjusted Payment SI N & NON 19 20 21 22 23 24 25 26 27 RC 361 450 363 940 CPT 29130 99285 90714 90471 APC 0000 5023 0000 0000 472.24 (504.51 x 60 x 0.8934) + (504,51 x.40) = 472.24 ZZZ Unadjusted Payment $ S 504,51 $ $ S N Total Reimbursement Profit or Loss

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