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Hugh Chatham Memorial Hospital, Inc. Charge Listing Effective October 1, 2019

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Hugh Chatham Memorial Hospital, Inc. Charge Listing Effective October 1, 2019 HUGH CHATHAM MEMORIAL HOSPITAL, INC. CHARGE LISTING EFFECTIVE OCTOBER 1, 2019 CHARGE REVENU SUM NUMBER CHARGE DESCRIPTION E CODE CODE CPT CODE PRICE MED-SURG DEPARTMENTS 44493225 ZIO HOOK UP > 48 HOURS (2ND FLOOR) 730 64 0296T $ 439.00 44436591 VAD- INTERNAL-SPECIMEN COLLECTION 761 8A 36591 $ 238.00 44496523 VAD- FLUSH ONLY 761 8A 96523 $ 65.00 44436592 VAD- EXTERNAL-SPECIMEN COLLECTION 761 8A 36592 $ 96.25 44436593 VAD - DECLOT 761 8A 36593 $ 649.00 44490472 VACCINE ADMINISTRATION EACH ADDITIONAL 771 7N 90472 $ 69.25 44490471 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 58.50 44492977 THROMBOLYTIC ADMIN CORONARY 480 68 92977 $ 1,342.75 44432554 THORACENTESIS, NEEDLE OR CATH ASPIRATION 940 77 32554 $ 1,514.25 44400140 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 276.75 44400111 TELE-PSYCH WITH IVC 510 28 Q3014 $ 276.75 44499986 TELEMETRY 2ND FL PATIENTS 732 TM $ 86.00 44499991 ROUTINE VENIPUNCTURE 300 55 36416 $ 9.25 44496415 REMICADE EACH ADDL HOUR 335 29 96415 $ 78.50 44499990 PULSE OX MONITORING 732 TM $ 101.25 49903553 PHASE III RECOVERY EA ADDL HR 710 36 $ 28.00 49903552 PHASE III RECOVERY 1ST HOUR 710 36 $ 205.75 49903556 PHASE 2 RECOVERY EA ADDL HR 710 36 $ 28.00 49903555 PHASE 2 RECOVERY 1ST HOUR 710 36 $ 205.75 44449082 PARACENTESIS 940 77 49082 $ 1,622.50 44400141 OUTPATIENT CLINIC VISIT 510 28 G0463 $ 207.75 44496368 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 65.00 44490781 IV THERAPY INFUSION EACH ADDL HR 940 77 96366 $ 43.25 44496367 IV SEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 65.00 44431110 IV PUSH INJECTION, INITIAL DRUG 940 77 96374 $ 216.25 44431112 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 43.25 44496376 IV PUSH INJECTION, EACH ADDL SAME DRUG 940 77 96376 $ 38.00 44490784 IV INFUSION FOR THERAPY 1ST HOUR 260 47 96365 $ 308.00 44403151 IV HYDRATION INITIAL, UP TO 1 HOUR 940 77 96360 $ 357.00 44490761 IV HYDRATION EACH ADDL HOUR 260 47 96361 $ 78.25 44436556 INSERTION OF CENTRAL LINE, NON TUNNELED 940 77 36556 $ 1,063.25 44432556 INSERT CATH PLEURA W/O IMAGE 940 77 32556 $ 3,136.75 44451702 INDWELLING URINARY CATH INSERTION 761 OF 51702 $ 227.25 44451701 IN/OUT CATH (FOR RESIDUAL) 761 OF 51701 $ 227.25 44490782 IM SUBQ INJECTION 940 77 96372 $ 65.00 44490379 DIRECT ADMISSION TO OBSERVATION 762 TR G0379 $ 4,471.25 44409612 CATH/ URINE SPECIMEN COLLECTION 300 55 P9612 $ 36.25 44431040 BLOOD ADMIN. 4 UNITS 391 61 36430 $ 1,677.50 44431030 BLOOD ADMIN. 3 UNITS 391 61 36430 $ 1,371.75 44431020 BLOOD ADMIN 2 UNITS 391 61 36430 $ 996.50 44431070 BLOOD ADMIN 1 UNIT 391 61 36430 $ 627.75 44451778 BLADDER SCAN (PHYSICIAN ORDERED) 761 8A 51798 $ 121.25 44490008 ADMINISTRATION PNEUMONIA VACCINE 771 7N G0009 $ 43.25 44496413 ADMINISTRATION OF REMICADE 1ST HOUR 335 29 96413 $ 536.50 44490791 ADMINISTRATION FLU VACCINE 771 7N G0008 $ 43.25 44490009 ADM PNEUMONIA VACCINE 771 7N G0009 $ 43.25 49903668 2ND FL OBSERATION PER HOUR 762 TR G0378 $ 33.25 33393225 ZIO HOOK UP> 48 HOURS (3RD FLOOR) 730 64 0296T $ 439.00 33336591 VAD-INTERNAL-SPECIMEN COLLECTION 761 8A 36591 $ 238.00 33336592 VAD-EXTERNAL-SPECIMEN COLLECTION 761 8A 36592 $ 96.25 33336593 VAD-DECLOT 761 8A 36593 $ 649.00 33396523 VAD - FLUSH ONLY 761 8A 96523 $ 65.00 33390471 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 58.50 33390472 VACCINE ADMINISTRAION EACH ADDITIONAL 771 7N 90472 $ 58.50 33332554 THORACENTESIS, NEEDLE OR CATH ASPIRATION 940 77 32554 $ 1,514.25 49900120 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 276.75 49900111 TELE-PSYCH WITH IVC 510 28 Q3014 $ 276.75 33390010 ROUTINE VENIPUNCTURE 300 55 36416 $ 9.25 33349082 PARACENTESIS 940 77 49082 $ 1,622.50 44403141 OUTPATIENT CLINIC VISIT 510 OC G0463 $ 207.75 33396368 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 65.00 33390781 IV THERAPY INFUSION EACH ADDL HOUR 940 77 96366 $ 43.25 33331112 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 43.25 44403133 IV PUSH INJECTION INITIAL DRUG 940 77 96374 $ 216.25 33331111 IV PUSH INJECTION EA ADDL SAME DRUG 940 77 96376 $ 38.00 33396367 IV ISEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 65.00 33390762 IV INFUSION FOR THERAPY 1ST HOUR 940 77 96365 $ 308.00 33390760 IV HYDRATION INITIAL, UP TO 1 HOUR 940 77 96360 $ 357.00 33090761 IV HYDRATION EACH ADDL HOUR 940 77 96361 $ 78.25 33336556 INSERTION OF CENTRAL LINE NON TUNNELED 940 77 36556 $ 1,063.25 33332556 INSERT CATH PLEURA W/O IMAGE 940 77 32556 $ 3,136.75 33351702 INDWELLING UINARY CATH INSERTION 761 8A 51702 $ 133.00 33351701 IN & OUT CATH (FOR RESIDUAL) 761 OF 51701 $ 227.25 33371080 IM SUBJ INJECTION 940 77 96372 $ 65.00 33390379 DIRECT ADMISSION TO OBSERVATION 762 TR G0379 $ 4,471.25 33379241 CONSULTATION-F/U <10 MINUTES 761 8A 99201 $ 141.75 33379244 CONSULTATION/FOLLOW-UP (46-60 MINS.) 761 8A 99204 $ 678.50 33379243 CONSULTATION/FOLLOWUP (31-45) MINUTES 761 OF 99203 $ 229.00 33377242 CONSULTATION/FOLLOW UP (10-30 MINUTES) 761 8A 99201 $ 154.25 33379242 CONSULTATION/FOLLOW UP (10-30 MIN) 761 8A 99202 $ 154.25 33379240 CONSULTATION (W/MD DOCUMENTATION) 761 8A 99201 $ 141.75 33379612 CATH/ URINE SPECIMEN COLLECTION 300 55 P9612 $ 36.25 44403158 BLOOD ADMIN. 4 UNITS 391 61 36430 $ 1,677.50 44403155 BLOOD ADMIN 3 UNITS 391 61 36430 $ 1,371.75 44403154 BLOOD ADMIN 2 UNITS 391 61 36430 $ 996.50 44403145 BLOOD ADMIN 1 UNIT 391 61 36430 $ 627.75 33351778 BLADDER SCAN (PHYSICIAN ORDER) 761 8A 51798 $ 121.25 33900009 ADMINSTRATION PNEUMONIA VACCINE 771 7N G0009 $ 43.25 33396413 ADMINISTRATION REMICADE 1ST HOUR 335 29 96413 $ 536.50 44403156 ADMINISTRATION OF REMICADE 1ST HOUR 335 29 96413 $ 536.50 33390008 ADMINISTRATION FLU VACCINE 771 7N G0008 $ 43.25 49903658 3RD FL OBSERVATION PER HOUR 762 TR G0378 $ 33.25 33396414 REMICADE EACH ADDL HOUR 335 29 96415 $ 78.50 49936591 VAD-INTERNAL SPECIMEN COLLECTION 761 8A 36591 $ 96.25 49936592 VAD-EXTERNAL-SPECIMEN COLLECTION 761 8A 36592 $ 96.25 49996523 VAD- FLUSH ONLY 761 8A 96523 $ 65.00 49936593 VAD DECLOT 761 8A 36593 $ 649.00 44403203 VACCINE ADMINISTRATION EACH ADDITIONAL 771 7N 90472 $ 69.25 44403176 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 58.50 49932554 THORACENTESIS, NEEDLE OR CATH ASPIRATION 940 77 32554 $ 1,514.25 44400220 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 276.75 44400210 TELE-PSYCH WITH IVC 510 28 Q3014 $ 276.75 44490001 ROUTINE VENIPUNCTURE 300 55 36416 $ 36.25 44964130 REMICADE EA ADDL HOUR 335 29 96415 $ 78.50 49949082 PARACENTESIS 940 77 49082 $ 1,622.50 49996368 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 65.00 44403159 IV THERAPY INFUSION EACH ADDL HOUR 940 77 96366 $ 43.25 49996367 IV SEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 65.00 44403172 IV PUSH INJECTION, INITIAL DRUG 940 77 96374 $ 216.25 33371050 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 43.25 44996376 IV PUSH INJECTION, EA ADDL SAME DRUG 940 77 96376 $ 38.00 44403165 IV INFUSION FOR THERAPY 1ST HOUR 260 47 96365 $ 308.00 44407152 IV HYDRATION INITIAL UP TO 1 HOUR 940 77 96360 $ 357.00 44403152 IV HYDRATION EACH ADDL HOUR 940 77 96361 $ 78.25 49936556 INSERTION OF CENTRAL LINE NON TUNNELED 940 77 36556 $ 1,063.25 49932556 INSERT CATH PLEURA W/O IMAGE 940 77 32556 $ 3,136.75 44403140 IM SUBQ INJECTION 940 77 96372 $ 65.00 23360004 ICU PARTIAL DAY CHG PER HOUR 233 15 $ 34.25 23300001 ICU PARTIAL DAY 1ST 4 HRS. 233 15 $ 138.25 49903638 ICU OBSERVATION PER HOUR 762 TR G0378 $ 33.25 44493000 EKG (ICU) 730 64 93005 $ 200.25 49990379 DIRECT ADMISSION TO OBSERVATION 762 TR G0379 $ 4,471.25 44403134 CATH/ URINE SPECIMEN COLLECTION 300 55 P9612 $ 36.25 44403168 BLOOD ADMIN. 4 UNITS 391 61 36430 $ 1,677.50 44403162 BLOOD ADMIN 3 UNITS 391 61 36430 $ 1,371.75 44403164 BLOOD ADMIN 2 UNITS 391 61 36430 $ 996.50 44403163 BLOOD ADMIN 1 UNIT 391 61 36430 $ 627.75 44451798 BLADDER SCAN PHYSICIAN ORDER 761 8A 51798 $ 121.25 44964150 ADMINISTRATION REMICADE 1ST HOUR. 335 29 96413 $ 536.50 68200009 ADMINISTRATION PNEUMONIA VACCINE 771 7N G0009 $ 43.25 44490792 ADMINISTRATION FLU VACCINE 771 7N G0008 $ 43.25 94297805 MNT, 2ND REFERRAL INDIV EA 15 MIN 942 DT G0270 $ 29.00 94297810 MNT, 2ND REFERRAL GROUP EA 30 MIN 942 DT G0271 $ 12.00 94297802 MEDICAL NUTRITION INDIV INITIAL 15 MIN 942 DT 97802 $ 36.25 94297804 MEDICAL NUTRITION GROUP 30 MIN 942 DT 97804 $ 21.75 94297803 MED NUTRITION INDIV SUBSEQ 15 MIN 942 DT 97803 $ 21.75 44403202 VACCINE ADMINISTRATION EACH ADDITIONAL 771 7N 90472 $ 69.25 44403199 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 58.50 44400150 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 276.75 44400110 TELE-PSYCH WITH IVC 510 28 Q3014 $ 276.75 44490789 TELEMETRY OB PATIENT 732 TM $ 86.00 30036416 REPEAT PKU LAB TEST 300 55 84030 $ 66.00 44403157 REMICADE EACH ADDL HOUR 335 29 96415 $ 78.50 47192552 PURE TONE AIR CONDUCTION THRESHOLD 471 8F 92551 $ 173.75 44403126 PULSE OX MONITOR 732 TM $ 101.25 49903541 PHASE III RECOVERY EA ADDL HOUR 710 36 $ 28.00 49903537 PHASE III RECOVERY 1ST HOUR 710 36 $ 205.75 49903562 PHASE 2 RECOVERY EA ADDL HOUR 710 36 $ 28.00 49903561 PHASE 2 RECOVERY 1ST HOUR 710 36 $ 205.75 71903568 OB RECOVERY 720 40 $ 213.00 49903678 OB OBSERVATION PER HOUR 762 TR G0378 $ 33.25 72003570 OB ANESTH 720 40 $ 161.25 44059025 NST 920 5H 59025 $ 611.25 72076805 LIMITED ULTRASOUND 402 71 76815 $ 439.00 44499205 LEVEL 5 (60 MIN) OUTPATIENT 510 28 99205 $ 315.00 44499204 LEVEL 4 (45 MIN) OUTPATIENT 510 28 99204 $ 236.25 49999209 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 65.00 44490785 IV THERAPY INFUSION EACH ADDL HOUR 940 77 96366 $ 43.25 49999208 IV SEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 65.00 44403193 IV PUSH INJECTION, INITIAL DRUG 940 77 96374 $ 216.25 44403195 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 43.25 44497029 IV PUSH INJECTION, EA ADDL SAME DRUG 940 77 96376 $ 38.00 44490788 IV INFUSION FOR THERAPY 1ST HOUR 940 77 96365 $ 308.00 44403189 IV HYDRATION INITIAL UP TO 1 HOUR 260 47 96360 $ 357.00 44403188 IV HYDRATION EACH ADDL HOUR 940 77 96361 $ 78.25 44403196 IN/OUT CATH (FOR RESIDUAL) 920 5H $ 154.25 44403128 IN & OUT CATH (FOR RESIDUAL) 761 8A 51701 $ 227.25 44403125 IM SUBQ INJECTION 940 77 96372 $ 65.00 72959026 FETAL MONT.
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