FaceSheet for JESUS MARTINEZ
Transcript of FaceSheet for JESUS MARTINEZ
FaceSheet for JESUS MARTINEZ
Member InformationDemographic Information:
Name: JESUS MARTINEZ Member ID: 1623703*01
Address: 11138 KADOTA AVEAPT A, POMONA, CA 91766
Sex: Male
Phone: (909) 326 - 1911 Date Of Birth: 05/17/1950E-Mail ID: Alt ID: 6NY2ER4VH14
Eligibility Details:
Member is EligibleLocation Name: ALL UNITED MEDICAL GROUP Benefit Option: H040A*MMLocation Phone: 909-264-3728 Health Plan Name: BND EMBRACE CHOICE 40 Benefit Option Description: H40-1 MM EMBRACE CHOICEEffective Date: 01/01/2021 HCC Risk Score: 0.000000000PCP ID: OCRU1 PCP Name: OCTAVIO RUIZ-VILLALPANDOHospital: Term Date:
Primary Treating Physician: Program Director:
Activity Center: Dental Information:
OHI: MFFS: MEDI-CAL FFS: :
Data Sharing Preference: Edit / View
Notes:No notes found.
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Problem ListICD Description Most Recent Encounter Most Recent Physician Original Encounter Original Physician
H43.11 VITREOUS HEMORRHAGE RIGHTEYE 12/22/2020 KHAN AYAZ 03/03/2020 KHAN AYAZ
E11.3513 DM II MEL PROL DIAB RETNOMACU 12/22/2020 KHAN AYAZ 02/06/2020 KHAN AYAZ
H40.1133 PRIMARY OPEN ANGLEGLAUCOMA 12/22/2020 KHAN AYAZ 02/06/2020 KHAN AYAZ
N18.4 CKD STAGE 4 SEVERE 12/21/2020 NEPHROLOGY ASSOC MG INC 01/21/2019 QUEST DIAGNOSTICS
E11.69 TYPE 2 DM W/OTHER SPECCOMPLICATION 12/21/2020 NEPHROLOGY ASSOC MG INC 08/08/2018 LANCE BONNIE
G47.00 INSOMNIA UNSPECIFIED 12/21/2020 NEPHROLOGY ASSOC MG INC 08/13/2020 TOMAS JAMES
F10.21 ALCOHOL DEPENDENCE INREMISSION 12/21/2020 NEPHROLOGY ASSOC MG INC 06/11/2020 TOMAS JAMES
F32.9 MAJ DEPRESS D/O SINGLE EPISUNS 12/21/2020 NEPHROLOGY ASSOC MG INC 06/11/2020 TOMAS JAMES
I10 ESSENTIAL PRIMARYHYPERTENSION 12/21/2020 NEPHROLOGY ASSOC MG INC 12/28/2018 RUIZ-VILLALPANDO OCTAVIO
N18.31 CHRONIC KIDNEY DISEASE,STAGE 12/17/2020 QUEST DIAGNOSTICS 12/17/2020 QUEST DIAGNOSTICS
E11.65 TYPE 2 DM W/HYPERGLYCEMIA 12/08/2020 DIABETES CARE PARTNERS 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
Z76.0 ENC FOR ISSUE REPEATPRESCRIPTION 09/28/2020 CONVEY HEALTH SOLUTIONS 05/05/2020 RUIZ-VILLALPANDO OCTAVIO
Z02.89 ENCOUNTER OTH ADMINEXAMINATIONS 09/23/2020 MEMBER PREVENTIVE CARE 06/03/2020 MEMBER PREVENTIVE CARE
U07.1 NCOV ACUTE RESPIRTAORYDISEASE 09/04/2020 RUIZ-VILLALPANDO OCTAVIO 07/22/2020 RUIZ-VILLALPANDO OCTAVIO
R53.83 OTHER FATIGUE 08/24/2020 RUIZ-VILLALPANDO OCTAVIO 08/24/2020 RUIZ-VILLALPANDO OCTAVIO
R06.02 SHORTNESS OF BREATH 08/24/2020 RUIZ-VILLALPANDO OCTAVIO 08/24/2020 RUIZ-VILLALPANDO OCTAVIO
D64.9 ANEMIA UNSPECIFIED 08/11/2020 HOSPITALIST CORP OF 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
N18.9 CHRONIC KIDNEY DISEASEUNSPECIFIED 08/11/2020 HOSPITALIST CORP OF 07/30/2020 POMONA VALLEY HOSPITAL
E87.1 HYPO-OSMOLALITY ANDHYPONATREMIA 08/11/2020 HOSPITALIST CORP OF 08/10/2020 POMONA VALLEY HOSPITAL
N17.9 ACUTE KIDNEY FAILUREUNSPECIFIED 08/10/2020 HOSPITALIST CORP OF 12/28/2018 QUEST DIAGNOSTICS
R55 SYNCOPE AND COLLAPSE 08/10/2020 HOSPITALIST CORP OF 08/10/2020 HOSPITALIST CORP OF
E87.5 HYPERKALEMIA 08/10/2020 CA EMERG PHYS POMONA 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
E86.0 DEHYDRATION 08/10/2020 CA EMERG PHYS POMONA 08/10/2020 POMONA VALLEY HOSPITAL
I49.9 CARDIAC ARRHYTHMIAUNSPECIFIED 08/10/2020 CHAPARRAL MEDICAL GROUP 08/10/2020 CHAPARRAL MEDICAL GROUP
D63.1 ANEMIA IN CHRONIC KIDNEYDISEASE
08/10/2020 POMONA VALLEY HOSPITAL 08/10/2020 POMONA VALLEY HOSPITAL
I12.9 HTN CKD W/STAGE 1-4CKD/UNS CKD 08/10/2020 POMONA VALLEY HOSPITAL 08/10/2020 POMONA VALLEY HOSPITAL
S09.90XA UNSPECIFIED INJURY HEADINITIAL ENC 08/10/2020 POMONA VALLEY HOSPITAL 08/10/2020 POMONA VALLEY HOSPITAL
E11.649 TYP 2 DM W/HYPOGLYCEMIAW/O COMA 08/10/2020 POMONA VALLEY HOSPITAL 08/10/2020 POMONA VALLEY HOSPITAL
R53.1 WEAKNESS 08/10/2020 POMONA VALLEY HOSPITAL 08/10/2020 POMONA VALLEY HOSPITAL
W19.XXXA UNSPECIFIED FALL INITIALENCOUNTER 08/10/2020 POMONA VALLEY HOSPITAL 08/10/2020 POMONA VALLEY HOSPITAL
R22.0 LOCALIZED SWELLING MASS &LUMP HEAD 08/10/2020 POMONA IMAGING MED GRP 08/10/2020 POMONA IMAGING MED GRP
R51 HEADACHE 08/10/2020 POMONA IMAGING MED GRP 08/10/2020 POMONA IMAGING MED GRP
M17.10 UNI PRIM OSTEOARTHRITIS UNSKNEE 08/04/2020 RUIZ-VILLALPANDO OCTAVIO 08/04/2020 RUIZ-VILLALPANDO OCTAVIO
H91.91 UNSPECIFIED HEARING LOSSRIGHT EAR 08/04/2020 RUIZ-VILLALPANDO OCTAVIO 08/04/2020 RUIZ-VILLALPANDO OCTAVIO
E78.5 HYPERLIPIDEMIA UNSPECIFIED 08/04/2020 RUIZ-VILLALPANDO OCTAVIO 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
Z03.818 ENC OBS EXPS OTH BIO AGTRULED OUT 07/30/2020 CA EMERG PHYS POMONA 07/30/2020 CA EMERG PHYS POMONA
B34.9 VIRAL INFECTION UNSPECIFIED 07/30/2020 CA EMERG PHYS POMONA 07/30/2020 CA EMERG PHYS POMONA
R50.81 FEVER PRESENTING W/CONDCLASS ELSW 07/30/2020 CA EMERG PHYS POMONA 07/30/2020 CA EMERG PHYS POMONA
R50.9 FEVER UNSPECIFIED 07/30/2020 POMONA VALLEY HOSPITAL 07/30/2020 POMONA VALLEY HOSPITAL
Z20.828 CONTCT EXPS OTH VIRLCOMMUNICABL DZ 07/30/2020 POMONA VALLEY HOSPITAL 07/30/2020 AMERICAN MED RESPONSE-INLAND
E11.22 TYPE 2 DM W/DIABETIC CKD 07/30/2020 POMONA VALLEY HOSPITAL 07/30/2020 POMONA VALLEY HOSPITAL
Z79.4 LONG TERM CURRENT USE OFINSULIN 07/30/2020 POMONA VALLEY HOSPITAL 04/09/2019 RUIZ-VILLALPANDO OCTAVIO
R05 COUGH 07/30/2020 POMONA VALLEY HOSPITAL 07/30/2020 POMONA VALLEY HOSPITAL
Z13.89 ENCOUNTER SCREEN FOROTHER DISORDER 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 05/05/2020 RUIZ-VILLALPANDO OCTAVIO
Z71.6 TOBACCO ABUSE COUNSELING 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 05/05/2020 RUIZ-VILLALPANDO OCTAVIO
Z00.00 ENC GEN ADULT EXAM W/OABNORM FIND 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
F33.9 MAJOR DEPRESSIVE D/ORECURRENT UNS 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 05/05/2020 RUIZ-VILLALPANDO OCTAVIO
Z71.3 DIETARY COUNSELING ANDSURVEILLANCE 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 05/05/2020 RUIZ-VILLALPANDO OCTAVIO
N18.3 CKD STAGE 3 MODERATE 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 12/28/2018 RUIZ-VILLALPANDO OCTAVIO
Z71.82 EXERCISE COUNSELING 05/05/2020 RUIZ-VILLALPANDO OCTAVIO 05/05/2020 RUIZ-VILLALPANDO OCTAVIO
Z68.27 BODY MASS INDEX BMI 27.0-27.9ADULT 10/09/2019 RUIZ-VILLALPANDO OCTAVIO 04/09/2019 RUIZ-VILLALPANDO OCTAVIO
H91.90 UNS HEARING LOSSUNSPECIFIED EAR 10/09/2019 RUIZ-VILLALPANDO OCTAVIO 07/01/2019 RUIZ-VILLALPANDO OCTAVIO
B35.1 TINEA UNGUIUM 08/22/2019 LANCE BONNIE 08/08/2018 LANCE BONNIE
E11.620 TYPE 2 DM W/DIABETICDERMATITIS 08/22/2019 LANCE BONNIE 08/08/2018 LANCE BONNIE
L08.9 LOCAL INFECT SKIN SUBQTISSUE UNS 08/22/2019 LANCE BONNIE 08/22/2019 LANCE BONNIE
Z68.28 BODY MASS INDEX BMI 28.0-28.9ADULT 07/01/2019 RUIZ-VILLALPANDO OCTAVIO 07/01/2019 RUIZ-VILLALPANDO OCTAVIO
Z76.89 PERS ENC HLTH SRVC OTHCIRCUMSTANCE 06/13/2019 ADRIANO ADRIAN 06/13/2019 ADRIANO ADRIAN
D68.2 HEREDITARY DEF OTHCLOTTING FACTORS 04/09/2019 RUIZ-VILLALPANDO OCTAVIO 04/09/2019 RUIZ-VILLALPANDO OCTAVIO
H93.19 TINNITUS UNSPECIFIED EAR 04/09/2019 RUIZ-VILLALPANDO OCTAVIO 04/09/2019 RUIZ-VILLALPANDO OCTAVIO
E11.40 TYPE 2 DM W/DIABETICNEUROPATHY UNS 04/09/2019 RUIZ-VILLALPANDO OCTAVIO 04/09/2019 RUIZ-VILLALPANDO OCTAVIO
E11.9 TYPE 2 DM WITHOUTCOMPLICATIONS 04/09/2019 QUEST DIAGNOSTICS 12/28/2018 RUIZ-VILLALPANDO OCTAVIO
N19 UNSPECIFIED KIDNEY FAILURE 01/27/2019 BEVERLY RAD MED GRP 01/27/2019 BEVERLY RAD MED GRP
Z01.00 ENC EXAM EYES VISION W/OABNRM FIND 01/21/2019 QUEST DIAGNOSTICS 09/07/2018 MEDICAL EYE SERVICES,
E11.618 TYP 2 DM W/OTH DIABETICARTHROPATHY
01/21/2019 QUEST DIAGNOSTICS 10/10/2018 HANGER PROS & ORTH RIVERSIDE
N14.0 ANALGESIC NEPHROPATHY 12/28/2018 RUIZ-VILLALPANDO OCTAVIO 12/28/2018 RUIZ-VILLALPANDO OCTAVIO
N39.0 UTI SITE NOT SPECIFIED 12/20/2018 RUIZ-VILLALPANDO OCTAVIO 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
E88.81 METABOLIC SYNDROME 12/20/2018 RUIZ-VILLALPANDO OCTAVIO 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
D30.00 BENIGN NEOPLASM UNSPECIFIEDKIDNEY 12/20/2018 RUIZ-VILLALPANDO OCTAVIO 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
R11.0 NAUSEA 12/20/2018 RUIZ-VILLALPANDO OCTAVIO 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
Z68.26 BODY MASS INDEX BMI 26.0-26.9ADULT 12/20/2018 RUIZ-VILLALPANDO OCTAVIO 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
R97.20 ELEVATED PROSTATE 12/20/2018 RUIZ-VILLALPANDO OCTAVIO 12/20/2018 RUIZ-VILLALPANDO OCTAVIO
Z01.812 ENCCOUNTER PREPROCEDURALLAB EXAM 12/10/2018 RUIZ-VILLALPANDO OCTAVIO 12/10/2018 RUIZ-VILLALPANDO OCTAVIO
J30.9 ALLERGIC RHINITISUNSPECIFIED 12/10/2018 RUIZ-VILLALPANDO OCTAVIO 12/10/2018 RUIZ-VILLALPANDO OCTAVIO
K21.9 GERD WITHOUT ESOPHAGITIS 11/19/2018 RUIZ-VILLALPANDO OCTAVIO 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
F41.9 ANXIETY DISORDERUNSPECIFIED 11/19/2018 RUIZ-VILLALPANDO OCTAVIO 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
Z23 ENCOUNTER FOR IMMUNIZATION 11/19/2018 RUIZ-VILLALPANDO OCTAVIO 11/19/2018 RUIZ-VILLALPANDO OCTAVIO
Claim History Date CPT / Description ICD Code / Description Physician Specialty Location
12/22/2020 67028 / INJECTION OF EYEDRUG
92014 / EYE EXAM &TREATMENT
92134 / CPTR OPHTH DX IMGPOST SEGMT
J9035 / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
H43.11 / VITREOUSHEMORRHAGE RIGHT EYE
KHAN AYAZ OPHTHALMOLOGY Office
12/21/2020 99443 / PHONE E/M BY PHYS 21-30 MIN
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
F10.21 / ALCOHOL DEPENDENCEIN REMISSION
F32.9 / MAJ DEPRESS D/OSINGLE EPIS UNS
G47.00 / INSOMNIAUNSPECIFIED
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
NEPHROLOGY ASSOC MG INC NEPHROLOGY
12/17/2020 36415 / COLLECT VENOUSBLOOD, VENIPU
80053 / COMPREHEN METABOLICPANEL
85027 / BLOOD COUNT, COMPLAUTO CBC
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
G47.00 / INSOMNIAUNSPECIFIED
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.31 / CHRONIC KIDNEYDISEASE, STAGE
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
12/08/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
12/08/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
12/01/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
12/01/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
11/24/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
11/24/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
11/17/2020 67028 / INJECTION OF EYEDRUG
92012 / INTERMED EYE EXAM,ESTAB PAT
92250 / FUNDUS PHOTOGRAPHY
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
H43.11 / VITREOUS
KHAN AYAZ OPHTHALMOLOGY Office
J9035 / INJECTION BEVACIZUMAB10 MG
HEMORRHAGE RIGHT EYE
11/10/2020 67028 / INJECTION OF EYEDRUG
92014 / EYE EXAM &TREATMENT
92134 / CPTR OPHTH DX IMGPOST SEGMT
J9035 / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
KHAN AYAZ OPHTHALMOLOGY Office
11/09/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
11/09/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
11/06/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
11/06/2020 G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
DIABETES CARE PARTNERS DIETICIAN
10/22/2020 99443 / PHONE E/M BY PHYS 21-30 MIN
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
F10.21 / ALCOHOL DEPENDENCEIN REMISSION
F32.9 / MAJ DEPRESS D/OSINGLE EPIS UNS
G47.00 / INSOMNIAUNSPECIFIED
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
NIELSON PAUL OPHTHALMOLOGY
10/17/2020 36415 / COLLECT VENOUSBLOOD, VENIPU
80053 / COMPREHEN METABOLICPANEL
81001 / URINALYSIS, AUTOMATEDW/MICR
82570 / ASSAY, CREATININE,OTHER SOU
83036 / GLYCOSYLATEDHEMOGLOBIN TEST
84156 / ASSAY OF PROTEIN,URINE
85027 / BLOOD COUNT, COMPLAUTO CBC
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
F10.21 / ALCOHOL DEPENDENCEIN REMISSION
G47.00 / INSOMNIAUNSPECIFIED
N18.4 / CKD STAGE 4 SEVERE
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
10/01/2020 67028 / INJECTION OF EYEDRUG
92014 / EYE EXAM &TREATMENT
92250 / FUNDUS PHOTOGRAPHY
J9035 / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
KHAN AYAZ OPHTHALMOLOGY Office
09/28/2020 99199 / UNLISTED SPECSERV,PROC,REP
S9430 / PHARMACY COMP/DISPSERV
Z76.0 / ENC FOR ISSUE REPEATPRESCRIPTION
CONVEY HEALTH SOLUTIONS COMMUNITY BASED SRVS Otherunlistedfacility
09/23/2020 99199 / UNLISTED SPECSERV,PROC,REP
Z02.89 / ENCOUNTER OTHADMIN EXAMINATIONS
MEMBER PREVENTIVE CARE MEMBER GIFT CARD Otherunlistedfacility
09/04/2020 E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
U07.1 / NCOV ACUTERESPIRTAORY DISEASE
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE
09/02/2020 76775 / ULTRSND EXAM,RETROPERITONEU
N18.4 / CKD STAGE 4 SEVERE BEVERLY RAD MED GRP DIAG RADIOLOGY Office
08/24/2020 R06.02 / SHORTNESS OFBREATH
R53.83 / OTHER FATIGUE
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE
U07.1 / NCOV ACUTERESPIRTAORY DISEASE
08/13/2020 99214 / OFFICE/OUTPT VISIT,EST, DET
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
F10.21 / ALCOHOL DEPENDENCEIN REMISSION
F32.9 / MAJ DEPRESS D/OSINGLE EPIS UNS
G47.00 / INSOMNIAUNSPECIFIED
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
TOMAS JAMES NEPHROLOGY
08/11/2020 99239 / HOSPITAL DISCHRGE DAYMGMT,
D64.9 / ANEMIA UNSPECIFIED
E87.1 / HYPO-OSMOLALITY ANDHYPONATREMIA
N18.9 / CHRONIC KIDNEYDISEASE UNSPECIFIED
U07.1 / NCOV ACUTERESPIRTAORY DISEASE
HOSPITALIST CORP OF HOSPITALIST Inpatient
08/10/2020 99223 / INITIAL HOSPITAL CARE,HIGH
D64.9 / ANEMIA UNSPECIFIED
E87.1 / HYPO-OSMOLALITY ANDHYPONATREMIA
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
R55 / SYNCOPE AND COLLAPSE
HOSPITALIST CORP OF HOSPITALIST Inpatient
08/10/2020 93010 / ELECTROCARDIOGRAMREPORT
99285 / EMERGENCY DEPT VISIT,HIGH C
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
E86.0 / DEHYDRATION
E87.5 / HYPERKALEMIA
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
CA EMERG PHYS POMONA EMERGENCY MEDICINE
08/10/2020 93010 / ELECTROCARDIOGRAMREPORT
I49.9 / CARDIAC ARRHYTHMIAUNSPECIFIED
CHAPARRAL MEDICAL GROUP MULTIPLE SPEC GRP Inpatient
08/10/2020 REVCD D63.1 / ANEMIA IN CHRONICKIDNEY DISEASE
E11.649 / TYP 2 DMW/HYPOGLYCEMIA W/O COMA
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
E86.0 / DEHYDRATION
E87.1 / HYPO-OSMOLALITY ANDHYPONATREMIA
E87.5 / HYPERKALEMIA
I12.9 / HTN CKD W/STAGE 1-4CKD/UNS CKD
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
N18.4 / CKD STAGE 4 SEVERE
R53.1 / WEAKNESS
S09.90XA / UNSPECIFIED INJURYHEAD INITIAL ENC
U07.1 / NCOV ACUTERESPIRTAORY DISEASE
W19.XXXA / UNSPECIFIED FALLINITIAL ENCOUNTER
POMONA VALLEY HOSPITAL HOSPITAL Inpatient
08/10/2020 70450 / CAT SCAN OFHEAD/BRAIN
R22.0 / LOCALIZED SWELLINGMASS & LUMP HEAD
R51 / HEADACHE
POMONA IMAGING MED GRP RADIOLOGY
08/04/2020 99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99442 / PHONE E/M BY PHYS 11-20 MIN
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
E78.5 / HYPERLIPIDEMIAUNSPECIFIED
H91.91 / UNSPECIFIED HEARINGLOSS RIGHT EAR
M17.10 / UNI PRIMOSTEOARTHRITIS UNS KNEE
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE
07/30/2020 93010 / ELECTROCARDIOGRAMREPORT
B34.9 / VIRAL INFECTIONUNSPECIFIED
CA EMERG PHYS POMONA EMERGENCY MEDICINE
99284 / EMERGENCY DEPT VISIT,DETAIL
I10 / ESSENTIAL PRIMARYHYPERTENSION
R50.81 / FEVER PRESENTINGW/COND CLASS ELSW
Z03.818 / ENC OBS EXPS OTHBIO AGT RULED OUT
07/30/2020 36415 / COLLECT VENOUSBLOOD, VENIPU
71045 / X-RAY EXAM CHEST 1VIEW
80048 / METABOLIC PANEL TOTALCA
85004 / BLOOD COUNT,AUTOMATED DIFF
85027 / BLOOD COUNT, COMPLAUTO CBC
93005 / ELECTROCARDIOGRAM,TRACING O
99284 / EMERGENCY DEPT VISIT,DETAIL
B34.9 / VIRAL INFECTIONUNSPECIFIED
E11.22 / TYPE 2 DM W/DIABETICCKD
N18.9 / CHRONIC KIDNEYDISEASE UNSPECIFIED
R05 / COUGH
R50.9 / FEVER UNSPECIFIED
Z20.828 / CONTCT EXPS OTHVIRL COMMUNICABL DZ
Z79.4 / LONG TERM CURRENTUSE OF INSULIN
POMONA VALLEY HOSPITAL HOSPITAL
07/30/2020 93010 / ELECTROCARDIOGRAMREPORT
99284 / EMERGENCY DEPT VISIT,DETAIL
B34.9 / VIRAL INFECTIONUNSPECIFIED
I10 / ESSENTIAL PRIMARYHYPERTENSION
R50.81 / FEVER PRESENTINGW/COND CLASS ELSW
Z03.818 / ENC OBS EXPS OTHBIO AGT RULED OUT
CA EMERG PHYS POMONA EMERGENCY MEDICINE
07/30/2020 A0425 / GROUND MILEAGE
A0427 / ALS1-EMERGENCY
Z20.828 / CONTCT EXPS OTHVIRL COMMUNICABL DZ
AMERICAN MED RESPONSE-INLAND AMBULANCE
07/22/2020 E87.5 / HYPERKALEMIA
U07.1 / NCOV ACUTERESPIRTAORY DISEASE
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE
07/09/2020 67028 / INJECTION OF EYEDRUG
92012 / INTERMED EYE EXAM,ESTAB PAT
92250 / FUNDUS PHOTOGRAPHY
J9035 / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
H43.11 / VITREOUSHEMORRHAGE RIGHT EYE
KHAN AYAZ OPHTHALMOLOGY Office
06/11/2020 99204 / OFFICE/OUTPATIENTVISIT, NE
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
F10.21 / ALCOHOL DEPENDENCEIN REMISSION
F32.9 / MAJ DEPRESS D/OSINGLE EPIS UNS
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
TOMAS JAMES NEPHROLOGY
06/03/2020 99199 / UNLISTED SPECSERV,PROC,REP
Z02.89 / ENCOUNTER OTHADMIN EXAMINATIONS
MEMBER PREVENTIVE CARE MEMBER GIFT CARD Otherunlistedfacility
05/05/2020 1159F / 1159F
G0270 / MNT SUBS TX FORCHANGE DX
G0447 / BEHAVIOR COUNSELOBESITY 15M
G8510 / PT INELIG NEG SCRNDEPRES
H0049 / ALCOHOL AND/OR DRUGSCREENIN
F33.9 / MAJOR DEPRESSIVE D/ORECURRENT UNS
N18.3 / CKD STAGE 3 MODERATE
Z00.00 / ENC GEN ADULT EXAMW/O ABNORM FIND
Z13.89 / ENCOUNTER SCREENFOR OTHER DISORDER
Z71.3 / DIETARY COUNSELINGAND SURVEILLANCE
Z71.6 / TOBACCO ABUSECOUNSELING
Z71.82 / EXERCISE COUNSELING
Z76.0 / ENC FOR ISSUE REPEATPRESCRIPTION
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE
05/05/2020 1160F / 1160F F33.9 / MAJOR DEPRESSIVE D/ORECURRENT UNS
N18.3 / CKD STAGE 3 MODERATE
Z00.00 / ENC GEN ADULT EXAM
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE
W/O ABNORM FIND
Z13.89 / ENCOUNTER SCREENFOR OTHER DISORDER
Z71.3 / DIETARY COUNSELINGAND SURVEILLANCE
Z71.6 / TOBACCO ABUSECOUNSELING
Z71.82 / EXERCISE COUNSELING
Z76.0 / ENC FOR ISSUE REPEATPRESCRIPTION
03/03/2020 67028 / INJECTION OF EYEDRUG
92012 / INTERMED EYE EXAM,ESTAB PAT
92134 / CPTR OPHTH DX IMGPOST SEGMT
J9035 / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
H43.11 / VITREOUSHEMORRHAGE RIGHT EYE
KHAN AYAZ OPHTHALMOLOGY Office
02/06/2020 67028 / INJECTION OF EYEDRUG
92012 / INTERMED EYE EXAM,ESTAB PAT
92134 / CPTR OPHTH DX IMGPOST SEGMT
J9035 / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPENANGLE GLAUCOMA
KHAN AYAZ OPHTHALMOLOGY Office
10/09/2019 3077F / SYST BP GËÑ 140 MMHG
3078F / DIAST BP < 80 MM HG
99213 / OFFICE/OUTPT VISIT,EST, EXP
D64.9 / ANEMIA UNSPECIFIED
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
H91.90 / UNS HEARING LOSSUNSPECIFIED EAR
I10 / ESSENTIAL PRIMARYHYPERTENSION
Z68.27 / BODY MASS INDEX BMI27.0-27.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
08/22/2019 99213 / OFFICE/OUTPT VISIT,EST, EXP
B35.1 / TINEA UNGUIUM
E11.620 / TYPE 2 DMW/DIABETIC DERMATITIS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
L08.9 / LOCAL INFECT SKINSUBQ TISSUE UNS
LANCE BONNIE PODIATRY Office
07/01/2019 3046F / HEMOGLOBIN A1C LEVEL> 9.0%
3077F / SYST BP GËÑ 140 MMHG
3079F / DIAST BP 80-89 MM HG
99213 / OFFICE/OUTPT VISIT,EST, EXP
B35.1 / TINEA UNGUIUM
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
H91.90 / UNS HEARING LOSSUNSPECIFIED EAR
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.3 / CKD STAGE 3 MODERATE
Z68.28 / BODY MASS INDEX BMI28.0-28.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
07/01/2019 3046F / HEMOGLOBIN A1C LEVEL> 9.0%
3077F / SYST BP GËÑ 140 MMHG
3079F / DIAST BP 80-89 MM HG
99213 / OFFICE/OUTPT VISIT,EST, EXP
B35.1 / TINEA UNGUIUM
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
H91.90 / UNS HEARING LOSSUNSPECIFIED EAR
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.3 / CKD STAGE 3 MODERATE
Z68.28 / BODY MASS INDEX BMI28.0-28.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
06/13/2019 1159F / 1159F
1160F / 1160F
Z76.89 / PERS ENC HLTH SRVCOTH CIRCUMSTANCE
ADRIANO ADRIAN PHARMACIST (PHARMD) Office
04/09/2019 3077F / SYST BP GËÑ 140 MMHG
3078F / DIAST BP < 80 MM HG
36415 / COLLECT VENOUSBLOOD, VENIPU
D68.2 / HEREDITARY DEF OTHCLOTTING FACTORS
E11.40 / TYPE 2 DM W/DIABETICNEUROPATHY UNS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
93000 / ELECTROCARDIOGRAM,COMPLETE
99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99397 / PER PM REEVAL EST PAT65+ YR
H93.19 / TINNITUS UNSPECIFIEDEAR
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.3 / CKD STAGE 3 MODERATE
Z68.27 / BODY MASS INDEX BMI27.0-27.9 ADULT
Z79.4 / LONG TERM CURRENTUSE OF INSULIN
04/09/2019 3077F / SYST BP GËÑ 140 MMHG
3078F / DIAST BP < 80 MM HG
36415 / COLLECT VENOUSBLOOD, VENIPU
93000 / ELECTROCARDIOGRAM,COMPLETE
99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99397 / PER PM REEVAL EST PAT65+ YR
D68.2 / HEREDITARY DEF OTHCLOTTING FACTORS
E11.40 / TYPE 2 DM W/DIABETICNEUROPATHY UNS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
H93.19 / TINNITUS UNSPECIFIEDEAR
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.3 / CKD STAGE 3 MODERATE
Z68.27 / BODY MASS INDEX BMI27.0-27.9 ADULT
Z79.4 / LONG TERM CURRENTUSE OF INSULIN
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
04/09/2019 80048 / METABOLIC PANEL TOTALCA
83036 / GLYCOSYLATEDHEMOGLOBIN TEST
85025 / BLD CNT, COMPL CBCW/AUTO DI
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
E11.9 / TYPE 2 DM WITHOUTCOMPLICATIONS
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
04/09/2019 80048 / METABOLIC PANEL TOTALCA
83036 / GLYCOSYLATEDHEMOGLOBIN TEST
85025 / BLD CNT, COMPL CBCW/AUTO DI
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
E11.9 / TYPE 2 DM WITHOUTCOMPLICATIONS
I10 / ESSENTIAL PRIMARYHYPERTENSION
N18.4 / CKD STAGE 4 SEVERE
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
01/27/2019 76770 / ULTRSND EXAMRETROPERITONEUM
N19 / UNSPECIFIED KIDNEYFAILURE
BEVERLY RAD MED GRP DIAG RADIOLOGY Office
01/21/2019 80048 / METABOLIC PANEL TOTALCA
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
Z00.00 / ENC GEN ADULT EXAMW/O ABNORM FIND
Z01.00 / ENC EXAM EYES VISIONW/O ABNRM FIND
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
01/21/2019 80048 / METABOLIC PANEL TOTALCA
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
Z00.00 / ENC GEN ADULT EXAMW/O ABNORM FIND
Z01.00 / ENC EXAM EYES VISIONW/O ABNRM FIND
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
01/21/2019 80048 / METABOLIC PANEL TOTALCA
E11.618 / TYP 2 DM W/OTHDIABETIC ARTHROPATHY
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
N18.4 / CKD STAGE 4 SEVERE
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
12/28/2018 99205 / OFFICE/OUTPATIENTVISIT, NE
E11.9 / TYPE 2 DM WITHOUTCOMPLICATIONS
E78.5 / HYPERLIPIDEMIAUNSPECIFIED
I10 / ESSENTIAL PRIMARYHYPERTENSION
N14.0 / ANALGESICNEPHROPATHY
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
N18.3 / CKD STAGE 3 MODERATE
12/28/2018 36415 / COLLECT VENOUSBLOOD, VENIPU
80048 / METABOLIC PANEL TOTALCA
N17.9 / ACUTE KIDNEY FAILUREUNSPECIFIED
QUEST DIAGNOSTICS LABORATORY IndependentLaboratory
12/20/2018 3075F / SYST BP 130 - 139MMHG
3078F / DIAST BP < 80 MM HG
36415 / COLLECT VENOUSBLOOD, VENIPU
99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99212 / OFFICE/OUTPT VISIT,EST, PRO
D30.00 / BENIGN NEOPLASMUNSPECIFIED KIDNEY
D64.9 / ANEMIA UNSPECIFIED
E87.5 / HYPERKALEMIA
E88.81 / METABOLIC SYNDROME
N39.0 / UTI SITE NOT SPECIFIED
R11.0 / NAUSEA
R97.20 / ELEVATED PROSTATE
Z68.26 / BODY MASS INDEX BMI26.0-26.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
12/20/2018 3075F / SYST BP 130 - 139MMHG
3078F / DIAST BP < 80 MM HG
36415 / COLLECT VENOUSBLOOD, VENIPU
99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99212 / OFFICE/OUTPT VISIT,EST, PRO
D30.00 / BENIGN NEOPLASMUNSPECIFIED KIDNEY
D64.9 / ANEMIA UNSPECIFIED
E87.5 / HYPERKALEMIA
E88.81 / METABOLIC SYNDROME
N39.0 / UTI SITE NOT SPECIFIED
R11.0 / NAUSEA
R97.20 / ELEVATED PROSTATE
Z68.26 / BODY MASS INDEX BMI26.0-26.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
12/10/2018 36415 / COLLECT VENOUSBLOOD, VENIPU
99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99211 / OFFICE/OUTPT VISIT,EST, MIN
J30.9 / ALLERGIC RHINITISUNSPECIFIED
Z01.812 / ENCCOUNTERPREPROCEDURAL LAB EXAM
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
12/10/2018 36415 / COLLECT VENOUSBLOOD, VENIPU
99000 / SPECIMENHNDLNG/TRNSPRT, OFF
99211 / OFFICE/OUTPT VISIT,EST, MIN
J30.9 / ALLERGIC RHINITISUNSPECIFIED
Z01.812 / ENCCOUNTERPREPROCEDURAL LAB EXAM
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
11/19/2018 3077F / SYST BP GËÑ 140 MMHG
3079F / DIAST BP 80-89 MM HG
90471 / IMMUNIZATION ADMIN
90686 / FLU VAC NO PRSV 4 VAL3 YRS+
99213 / OFFICE/OUTPT VISIT,EST, EXP
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
E78.5 / HYPERLIPIDEMIAUNSPECIFIED
F41.9 / ANXIETY DISORDERUNSPECIFIED
K21.9 / GERD WITHOUTESOPHAGITIS
Z00.00 / ENC GEN ADULT EXAMW/O ABNORM FIND
Z23 / ENCOUNTER FORIMMUNIZATION
Z68.26 / BODY MASS INDEX BMI26.0-26.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
11/19/2018 3077F / SYST BP GËÑ 140 MMHG
3079F / DIAST BP 80-89 MM HG
90471 / IMMUNIZATION ADMIN
90686 / FLU VAC NO PRSV 4 VAL3 YRS+
99213 / OFFICE/OUTPT VISIT,EST, EXP
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
E78.5 / HYPERLIPIDEMIAUNSPECIFIED
F41.9 / ANXIETY DISORDERUNSPECIFIED
K21.9 / GERD WITHOUTESOPHAGITIS
Z00.00 / ENC GEN ADULT EXAMW/O ABNORM FIND
Z23 / ENCOUNTER FORIMMUNIZATION
Z68.26 / BODY MASS INDEX BMI26.0-26.9 ADULT
RUIZ-VILLALPANDO OCTAVIO FAMILY PRACTICE Office
10/10/2018 A5500 / DIABETIC SHOE FORDENSITY IN
A5513 / FOR DIAB ONLY MXDNSITY INSR
E11.618 / TYP 2 DM W/OTHDIABETIC ARTHROPATHY
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
HANGER PROS & ORTH RIVERSIDE ORTHOTICS/PROSTHETIC Home
09/19/2018 11721 / DEBRIDE NAIL, 6 ORMORE
B35.1 / TINEA UNGUIUM
E11.620 / TYPE 2 DMW/DIABETIC DERMATITIS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
LANCE BONNIE PODIATRY Office
09/19/2018 11721 / DEBRIDE NAIL, 6 ORMORE
B35.1 / TINEA UNGUIUM
E11.620 / TYPE 2 DMW/DIABETIC DERMATITIS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
LANCE BONNIE PODIATRY Office
09/07/2018 V2020 / VISION SVCS FRAMESPURCHASES
V2303 / LENS SPHCYL TRIFOCAL4.0/.12
V2744 / TINT PHOTOCHROMATICLENS/ES
Z01.00 / ENC EXAM EYES VISIONW/O ABNRM FIND
MEDICAL EYE SERVICES, OPTOMETRY Office
08/08/2018 99204 / OFFICE/OUTPATIENTVISIT, NE
B35.1 / TINEA UNGUIUM
E11.620 / TYPE 2 DMW/DIABETIC DERMATITIS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
LANCE BONNIE PODIATRY Office
08/08/2018 99204 / OFFICE/OUTPATIENTVISIT, NE
B35.1 / TINEA UNGUIUM
E11.620 / TYPE 2 DMW/DIABETIC DERMATITIS
E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION
LANCE BONNIE PODIATRY Office
Flow Sheet
Vital Signs
Lab
Test Unit 03/26/2021 02/16/2021 02/15/2021 12/17/2020 01/22/2019WHITE BLOOD CELL COUNT Thousand/uL 9.5 6.8 7.8
UREA NITROGEN (BUN) mg/dL 43 [H] 39 [H] 34 [H] 26 [H]
SODIUM mmol/L 139 137 138 137
RED BLOOD CELL COUNT Million/uL 4.26 4.38 4.54
RDW % 14.2 13.6 14.1
PROTEIN/CREATININE RATIO mg/g creat 770 [H]
PROTEIN, TOTAL, 24 HR UR mg/24 h 824 [H]
PROTEIN, TOTAL g/dL 7.7 7.4 7.4
POTASSIUM mmol/L 5.1 5.3 5.1 4.8
PLATELET COUNT Thousand/uL 355 233 273
MPV fL 9.7 10.6 10.2
MCV fL 84.3 86.1 85.0
MCHC g/dL 33.4 32.9 33.2
MCH pg 28.2 28.3 28.2
HEMOGLOBIN A1c % of total Hgb 13.5 [H]
HEMOGLOBIN g/dL 12.0 [L] 12.4 [L] 12.8 [L]
HEMATOCRIT % 35.9 [L] 37.7 [L] 38.6
GLUCOSE mg/dL 260 [H] 293 [H] 160 [H] 172 [H]
GLOBULIN g/dL (calc) 3.6 3.4 3.4
eGFR NON-AFR. AMERICAN mL/min/1.73m2 30 [L] 31 [L] 26 [L] 45 [L]
eGFR AFRICAN AMERICAN mL/min/1.73m2 35 [L] 35 [L] 30 [L] 52 [L]
CREATININE, 24 HOUR URINE g/24 h 1.07
CREATININE mg/dL 2.16 [H] 2.12 [H] 2.41 [H] 1.57 [H]
CHLORIDE mmol/L 104 103 105 106
CARBON DIOXIDE mmol/L 27 26 27 23
Vital Signs Unit No records found for the member.
MetricStandard
Lipid Panel Renal Panel Diabetes PanelALL
CALCIUM mg/dL 9.9 9.0 9.5 8.6
BUN/CREATININE RATIO (calc) 20 18 14 17
BILIRUBIN, TOTAL mg/dL 0.4 0.4 0.3
AST U/L 17 18 16
ALT U/L 19 19 9
ALKALINE PHOSPHATASE U/L 151 [H] 112 81
ALBUMIN/GLOBULIN RATIO (calc) 1.1 1.2 1.2
ALBUMIN g/dL 4.1 4.0 4.0
Referral Data DateReferred
Referral Code Referred Provider Specialty CPT HCPCS Code ICD's Status
03/31/2021 2021033122261353 KHAN AYAZ OPHTHALMOLOGY 67028-RT / INJECTION OF EYE DRUG
92014-25 / EYE EXAM & TREATMENT
92134 / CPTR OPHTH DX IMG POSTSEGMT
J9035-RT / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPEN ANGLEGLAUCOMA
VOID
02/10/2021 2021021022248706 KHAN AYAZ OPHTHALMOLOGY 67028-LT / INJECTION OF EYE DRUG
92014-25 / EYE EXAM & TREATMENT
92134 / CPTR OPHTH DX IMG POSTSEGMT
J9035-LT / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPEN ANGLEGLAUCOMA
VOID
12/23/2020 2020122322238423 KHAN AYAZ OPHTHALMOLOGY 67028-RT / INJECTION OF EYE DRUG
92012-25 / INTERMED EYE EXAM,ESTAB PAT
92250 / FUNDUS PHOTOGRAPHY
J9035-RT / INJECTION BEVACIZUMAB10 MG
E11.3513 / DM II MEL PROL DIABRETNO MACU
H40.1133 / PRIMARY OPEN ANGLEGLAUCOMA
H43.11 / VITREOUS HEMORRHAGERIGHT EYE
VOID
11/30/2020 2039545*OP DIABETES CAREPARTNERS
DIETICIAN G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
APPROVED
11/06/2020 2032899*OP DIABETES CAREPARTNERS
DIETICIAN G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
APPROVED
11/06/2020 2032513*OP DIABETES CAREPARTNERS
DIETICIAN G0108 / DIABETES OP SELF-MGTSVCS, I
E11.65 / TYPE 2 DMW/HYPERGLYCEMIA
APPROVED
Case DataCase Number
Admit Date
Facility
LOS
Bed
Admit Diagnosis
LOC
Attending Physician
Status
Discharge Date
Medication List
Date Brand Name GenericName Strength Dosage
Form Days Supply Formulary
No records found for the member