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: :

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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


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


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




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

















92012 / INTERMED EYE EXAM,ESTAB PAT

92250 / FUNDUS PHOTOGRAPHY



H43.11 / VITREOUS



HEMORRHAGE RIGHT EYE




















10/22/2020 99443 / PHONE E/M BY PHYS 21-30 MIN







NIELSON PAUL OPHTHALMOLOGY


80053 / COMPREHEN METABOLICPANEL

81001 / URINALYSIS, AUTOMATEDW/MICR

82570 / ASSAY, CREATININE,OTHER SOU

83036 / GLYCOSYLATEDHEMOGLOBIN TEST

84156 / ASSAY OF PROTEIN,URINE














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


Z02.89 / ENCOUNTER OTHADMIN EXAMINATIONS

MEMBER PREVENTIVE CARE MEMBER GIFT CARD Otherunlistedfacility

09/04/2020 E11.69 / TYPE 2 DM W/OTHERSPEC COMPLICATION



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



08/13/2020 99214 / OFFICE/OUTPT VISIT,EST, DET







TOMAS JAMES NEPHROLOGY

08/11/2020 99239 / HOSPITAL DISCHRGE DAYMGMT,

D64.9 / ANEMIA UNSPECIFIED

E87.1 / HYPO-OSMOLALITY ANDHYPONATREMIA

N18.9 / CHRONIC KIDNEYDISEASE UNSPECIFIED


HOSPITALIST CORP OF HOSPITALIST Inpatient

08/10/2020 99223 / INITIAL HOSPITAL CARE,HIGH



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


E86.0 / DEHYDRATION

E87.5 / HYPERKALEMIA


CA EMERG PHYS POMONA EMERGENCY MEDICINE


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


E86.0 / DEHYDRATION



I12.9 / HTN CKD W/STAGE 1-4CKD/UNS CKD



R53.1 / WEAKNESS

S09.90XA / UNSPECIFIED INJURYHEAD INITIAL ENC


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


E78.5 / HYPERLIPIDEMIAUNSPECIFIED

H91.91 / UNSPECIFIED HEARINGLOSS RIGHT EAR

M17.10 / UNI PRIMOSTEOARTHRITIS UNS KNEE



B34.9 / VIRAL INFECTIONUNSPECIFIED


99284 / EMERGENCY DEPT VISIT,DETAIL


R50.81 / FEVER PRESENTINGW/COND CLASS ELSW

Z03.818 / ENC OBS EXPS OTHBIO AGT RULED OUT


71045 / X-RAY EXAM CHEST 1VIEW

80048 / METABOLIC PANEL TOTALCA

85004 / BLOOD COUNT,AUTOMATED DIFF


93005 / ELECTROCARDIOGRAM,TRACING O



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





R50.81 / FEVER PRESENTINGW/COND CLASS ELSW

Z03.818 / ENC OBS EXPS OTHBIO AGT RULED OUT


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











06/11/2020 99204 / OFFICE/OUTPATIENTVISIT, NE






TOMAS JAMES NEPHROLOGY


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



05/05/2020 1160F / 1160F F33.9 / MAJOR DEPRESSIVE D/ORECURRENT UNS


Z00.00 / ENC GEN ADULT EXAM


W/O ABNORM FIND

Z13.89 / ENCOUNTER SCREENFOR OTHER DISORDER

Z71.3 / DIETARY COUNSELINGAND SURVEILLANCE

Z71.6 / TOBACCO ABUSECOUNSELING

Z71.82 / EXERCISE COUNSELING

















10/09/2019 3077F / SYST BP GËÑ 140 MMHG

3078F / DIAST BP < 80 MM HG

99213 / OFFICE/OUTPT VISIT,EST, EXP



H91.90 / UNS HEARING LOSSUNSPECIFIED EAR


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


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









07/01/2019 3046F / HEMOGLOBIN A1C LEVEL> 9.0%

3077F / SYST BP GËÑ 140 MMHG










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


36415 / COLLECT VENOUSBLOOD, VENIPU

D68.2 / HEREDITARY DEF OTHCLOTTING FACTORS

E11.40 / TYPE 2 DM W/DIABETICNEUROPATHY UNS



93000 / ELECTROCARDIOGRAM,COMPLETE

99000 / SPECIMENHNDLNG/TRNSPRT, OFF

99397 / PER PM REEVAL EST PAT65+ YR

H93.19 / TINNITUS UNSPECIFIEDEAR





04/09/2019 3077F / SYST BP GËÑ 140 MMHG



93000 / ELECTROCARDIOGRAM,COMPLETE


99397 / PER PM REEVAL EST PAT65+ YR

D68.2 / HEREDITARY DEF OTHCLOTTING FACTORS

E11.40 / TYPE 2 DM W/DIABETICNEUROPATHY UNS


H93.19 / TINNITUS UNSPECIFIEDEAR






04/09/2019 80048 / METABOLIC PANEL TOTALCA


85025 / BLD CNT, COMPL CBCW/AUTO DI


E11.9 / TYPE 2 DM WITHOUTCOMPLICATIONS






85025 / BLD CNT, COMPL CBCW/AUTO DI






01/27/2019 76770 / ULTRSND EXAMRETROPERITONEUM

N19 / UNSPECIFIED KIDNEYFAILURE

BEVERLY RAD MED GRP DIAG RADIOLOGY Office





Z01.00 / ENC EXAM EYES VISIONW/O ABNRM FIND









E11.618 / TYP 2 DM W/OTHDIABETIC ARTHROPATHY









N14.0 / ANALGESICNEPHROPATHY




80048 / METABOLIC PANEL TOTALCA



12/20/2018 3075F / SYST BP 130 - 139MMHG




99212 / OFFICE/OUTPT VISIT,EST, PRO

D30.00 / BENIGN NEOPLASMUNSPECIFIED KIDNEY



E88.81 / METABOLIC SYNDROME

N39.0 / UTI SITE NOT SPECIFIED

R11.0 / NAUSEA

R97.20 / ELEVATED PROSTATE



12/20/2018 3075F / SYST BP 130 - 139MMHG




99212 / OFFICE/OUTPT VISIT,EST, PRO

D30.00 / BENIGN NEOPLASMUNSPECIFIED KIDNEY



E88.81 / METABOLIC SYNDROME

N39.0 / UTI SITE NOT SPECIFIED

R11.0 / NAUSEA

R97.20 / ELEVATED PROSTATE





99211 / OFFICE/OUTPT VISIT,EST, MIN

J30.9 / ALLERGIC RHINITISUNSPECIFIED

Z01.812 / ENCCOUNTERPREPROCEDURAL LAB EXAM




99211 / OFFICE/OUTPT VISIT,EST, MIN

J30.9 / ALLERGIC RHINITISUNSPECIFIED

Z01.812 / ENCCOUNTERPREPROCEDURAL LAB EXAM


11/19/2018 3077F / SYST BP GËÑ 140 MMHG


90471 / IMMUNIZATION ADMIN

90686 / FLU VAC NO PRSV 4 VAL3 YRS+




F41.9 / ANXIETY DISORDERUNSPECIFIED

K21.9 / GERD WITHOUTESOPHAGITIS


Z23 / ENCOUNTER FORIMMUNIZATION



11/19/2018 3077F / SYST BP GËÑ 140 MMHG


90471 / IMMUNIZATION ADMIN

90686 / FLU VAC NO PRSV 4 VAL3 YRS+




F41.9 / ANXIETY DISORDERUNSPECIFIED

K21.9 / GERD WITHOUTESOPHAGITIS


Z23 / ENCOUNTER FORIMMUNIZATION



10/10/2018 A5500 / DIABETIC SHOE FORDENSITY IN

A5513 / FOR DIAB ONLY MXDNSITY INSR

E11.618 / TYP 2 DM W/OTHDIABETIC ARTHROPATHY


HANGER PROS & ORTH RIVERSIDE ORTHOTICS/PROSTHETIC Home

09/19/2018 11721 / DEBRIDE NAIL, 6 ORMORE





09/19/2018 11721 / DEBRIDE NAIL, 6 ORMORE





09/07/2018 V2020 / VISION SVCS FRAMESPURCHASES

V2303 / LENS SPHCYL TRIFOCAL4.0/.12

V2744 / TINT PHOTOCHROMATICLENS/ES


MEDICAL EYE SERVICES, OPTOMETRY 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


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



VOID

12/23/2020 2020122322238423 KHAN AYAZ OPHTHALMOLOGY 67028-RT / INJECTION OF EYE DRUG

92012-25 / INTERMED EYE EXAM,ESTAB PAT


J9035-RT / INJECTION BEVACIZUMAB10 MG



H43.11 / VITREOUS HEMORRHAGERIGHT EYE

VOID

11/30/2020 2039545*OP DIABETES CAREPARTNERS

DIETICIAN G0108 / DIABETES OP SELF-MGTSVCS, I


APPROVED




APPROVED




APPROVED

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