University Of Texas Md Anderson

 

 

Attn

 

 

Title

 

 

Street

 

 

Houston, TX   Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Number: 

 

 

 

 

 

Subscriber Number: 

 

 

 

 

 

Claim Number: 

 

 

 

 

 

Patient Name: 

 

 

 

 

 

Patient Cntrl: 

 

 

 

 

 

Provider Name: University Of Texas Md Anderson

 

 

 

 

 

Service Date: 09/11/2019

 

 

 

 

 

SysID:

 

 

 

 

 

 

 

 

 

 

 

 

 

12/27/2019

 

 

 

 

 

 

 

 

 

 

 

 

Dear Provider:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The above referenced claim and itemized bill statement have been compared to our Clinical Payment & Coding Policy CPCP002 - Inpatient/Outpatient Unbundling. Based on this policy the charges below are not eligible for payment. Disposition of the claim is in process. These ineligible charges will be reflected in the provider write-off amount.                                                                                                                                                             

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

636

 

J2997

ALTEPLASE 2 MG SOLR 1 EACH VIAL

3

$150.00

$450.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

343

 

A9552

FLUORINE F-18 FLUDEOXYGLUCOSE 20 MCI TO 300 MCI/ML SOLN

1

$994.00

$994.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

271

 

 

HC ARMBOARD IV ART ADLT3X9IN

1

$22.00

$22.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

761

 

36600

HC ARTERIAL PUNCTURE - MAIN LEUKEMIA LAB

1

$59.00

$59.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

271

 

E0700

HC BELT GAIT/TRANSFER

1

$23.00

$23.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

391

 

36430

HC BLOOD ADMIN IP BUNDLED

1

$0.01

$0.01

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

278

 

C1751

HC CATHETHER KIT ARTERIAL CHLORAPREP 20GX5CM

2

$85.00

$170.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

761

 

36591

HC CENTRAL VENOUS ACCESS - MAIN LEUKEMIA LAB

1

$70.00

$70.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

761

 

36591

HC CENTRAL VENOUS ACCESS - MAIN LEUKEMIA LAB

1

$70.00

$70.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

761

 

36591

HC CENTRAL VENOUS ACCESS - MAIN LEUKEMIA LAB

1

$70.00

$70.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

271

 

E2603

HC CUSHION SEGMENTED 4X16X18IN

1

$100.00

$100.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

623

 

A6209

HC CVC DRESNG TRAY BIOPATCH

1

$35.00

$35.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

623

 

A6257

HC CVC DRESNG TRAY TEGADERM

1

$38.00

$38.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

623

 

A9209

HC CVC DRESNG TRAY TEGADERM

1

$35.00

$35.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

623

 

A6257

HC CVC DRESNG TRAY TEGADERM

1

$38.00

$38.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

623

 

A6257

HC CVC DRESNG TRAY TEGADERM

1

$38.00

$38.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

08/29/2019

761

 

36593

HC DECLOT VENOUS ACC DEV

1

$595.00

$595.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

272

 

A6209

HC DRESSING BIOPATCH DISK .75IN 1.5MM

1

$22.00

$22.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

272

 

A6402

HC DRESSING GAUZE 6IN

1

$38.00

$38.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

623

 

A6214

HC DRESSING MEPILEX 9.9X9.9/KERRAFOAM BORDER SACRUM 9X10

2

$38.00

$76.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

636

 

A6214

HC DRESSING MEPILEX 9.9X9.9/KERRAFOAM BORDER SACRUM 9X10

1

$24.00

$24.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

623

 

A6203

HC DRESSING VAD 4IN*4IN CVRDRM PL

1

$3.00

$3.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/08/2019

623

 

A6203

HC DRESSING VAD 4IN*4IN CVRDRM PL

3

$3.00

$9.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

430

 

A6203

HC DRESSING VAD 4IN*4IN CVRDRM PL

3

$3.00

$9.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

623

 

A6203

HC DRESSING VAD 4IN*4IN CVRDRM PL

1

$3.00

$3.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

623

 

A6203

HC DRESSING VAD 4IN*4IN CVRDRM PL

2

$3.00

$6.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/07/2019

623

 

A6214

HC DRESSNG MEPLIEX 7.2X7.2IN/KERRAFOAM BORDER SACRUM 6.7X6.9

1

$24.00

$24.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

270

 

 

HC ENVISION MATTRESS DAILY

1

$137.00

$137.00

 

0001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

271

 

A9284

HC INCENTIVE SPIROMETER

1

$9.00

$9.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

272

 

 

HC LEUKOCYTE DEPLE PLT

1

$146.00

$146.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

272

 

 

HC LEUKOCYTE DEPLE PLT

1

$146.00

$146.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

272

 

 

HC LEUKOCYTE DEPLE PLT

1

$146.00

$146.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

257

 

 

HC NUTREN 1.5 1L EA

1

$7.00

$7.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

271

 

A6250

HC OINTMNT RMDY CLRAID 2.5 OZ

1

$18.00

$18.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

3

$67.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

3

$67.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/03/2019

410

 

94640

HC OSCILLATORY PEP SUBSEQUENT

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/10/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

301

 

82962

HC POC GLUCOSE MONITORING

1

$62.00

$62.00

 

0003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC POS. PRESS BREATHING SUB

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

272

 

B4035

HC PUMP SET KANGAROO 1000ML

1

$9.00

$9.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

710

 

 

HC RECOVERY ROOM TIER2 1 HR

1

$1,339.00

$1,339.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/03/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

-1

$48.00

($48.00)

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

300

 

36415

HC ROUTINE VENIPUNCTURE- MAIN LEUKEMIA LAB

1

$48.00

$48.00

 

0007

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

4

$120.00

$480.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

2

$120.00

$240.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

4

$120.00

$480.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

1

$120.00

$120.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

07/29/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

2

$115.00

$230.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

3

$120.00

$360.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

1

$120.00

$120.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

3

$120.00

$360.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

3

$120.00

$360.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

1

$120.00

$120.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

4

$120.00

$480.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

3

$120.00

$360.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

3

$120.00

$360.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

1

$120.00

$120.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

3

$120.00

$360.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/03/2019

430

 

97535

HC SELF CARE HOME TRN 15 MIN

4

$120.00

$480.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

1

$120.00

$120.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

420

 

97535

HC SELF CARE HOME TRN 15 MIN

1

$120.00

$120.00

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

272

 

 

HC SPIKE RT PLUS KANGARO SET

1

$7.00

$7.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

623

 

A6402

HC SPONGE DRAIN STER 4IN*4IN

5

$14.00

$70.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

271

 

A4450

HC TAPE MEDIPORE 4IN

1

$26.00

$26.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

272

 

 

HC TRAY SUTURE REMOVAL CUSTOM

1

$13.00

$13.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

272

 

A4331

HC TUBE DEVICE ATTACH SUCTION

1

$9.00

$9.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

272

 

 

HC TUBE FEEDING 8FR (DOBHOFF)

1

$32.00

$32.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/01/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/03/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/03/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/17/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/16/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/18/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/22/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/21/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/13/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/15/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/14/2019

410

 

94640

HC UPDRAFT NEBULIZER SUBSEQU

1

$201.00

$201.00

 

0004

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

271

 

A4358

HC URINARY LEG BAG 30 OZ

2

$26.00

$52.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

623

 

A4602

HD SPONGE DRAIN STER 4IN*4IN

6

$14.00

$84.00

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/25/2019

250

 

J1642

HEPARIN (PF) 100 UNITS/ML SYRG

20

$0.32

$6.40

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

636

 

J2704

PROPOFOL 10 MG/ML EMUL

6

$1.28

$7.65

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

636

 

J2704

PROPOFOL 10 MG/ML EMUL

10

$1.21

$12.05

 

0011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/27/2019

250

 

 

SMOG ENEM

1

$38.35

$38.35

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/02/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

636

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/30/2019

636

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/28/2019

636

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/29/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/26/2019

636

 

J7030

SODIUM CHLORIDE 0.9% SOLP

1

$69.65

$69.65

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/24/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/11/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/12/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/23/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/20/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

09/19/2019

258

 

J7050

SODIUM CHLORIDE 0.9% SOLP

1

$66.15

$66.15

 

0002

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total :

$41,914.97

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association

 

 

 

 

 

 

Date of Service

Revenue Code

Service, Billing, Procedure, or Other Code

HCPC/CPT or Other Code

Description

Units

Cost Per  Unit

Billed Amount

Message Code

Message Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Message Code Descriptions:

001

Patient comfort/convenience items

002

Daily or bundled supply charges;

these charges are included in the general cost of the room or bundled to the procedure performed.

003

Incremental nursing special or personnel charges;

these charges are part of the room rate billed for the date of service. 

004

Ventilator/respiratory equipment and personnel charges for related respiratory support in the elevated room setting; 

these charges are part of the support covered by the elevated room & board Revenue Codes, as defined in the UB-04 billing manuals

007

Draw fees, venipuncture fees, collection charges;

these charges are included with laboratory tests or procedures performed.

011

Incidental or bundled service charges; these charges are included in the general cost of the room or incidental to the procedure performed.

 

 

 

 

 

 

 

 

 

A copy of the most current policy can be found here: https://www.bcbstx.com/provider/pdf/cpcp002_inpatient_outpatient_unbundling.pdf

Or by going to: https://www.bcbstx.com/provider/standards/cpcp.html, and clicking on the link to Inpatient/Outpatient Unbundling.

If you have any questions, please contact:

 

 

 

 

 

 

 

 

 

Sincerely,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blue Cross Blue Shield of Texas

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

bcbstx.com

 

 

 

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,

 

 

an Independent Licensee of the Blue Cross and Blue Shield Association