Case Management Closure {C-34}

FORM C-34 TENNESSEE DEPARTMENT OF LABO R AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 CASE MANAGEMENT CLOSURE EMPLOYEE INFORMATION State File # _______________ Date of Injury_____________ County of Injury ________________________ Claimant _________________________________________Social Security #______________________ DOB __________________ Sex _________ Occupation ________________________________EMPLOYER INFORMATION FEIN: ___________________Employer:_______________________________________________________ Street: _________________________ City: State: Zip: __________________INSURER INFORMATION Insurer: ________________________________________________________________________________ Insurer Claim #:_____________________________ Policy Number: _____________________________ Last Name First Name MD/DO/Chiro License#Physician(s) The reverse side of this form must be completed or all applicable diagnosis (ICD9) and procedure (CPT) codes must be listed in the areas below. Diagnosis: _________________________________________________________________________ ___________________________________________________________________________________ Procedures: ________________________________________________________________________ ___________________________________________________________________________________ Total Weeks Case ManagemenOpet n __________________ Date Csea Closed ___________________ Total Cost of Case Management _________________________________________________________ Medical Savings $_______________ How Saved: ___________negotiated providefra/cility discount, ____________ arranged home PT, ___________avoided unnecessary ER visits, ____________ prevented duplicate testing,Other ______________________________________________________________________________ ___________________________________________________________________________________ Indemnity Savings $______________ How Saved: ______________ coordinated modified duty, ______________facilitated early RTW, ______________ assisted in making claim no lost time, Other ______________________________________________________________________________ ___________________________________________________________________________________ Case Management Porvider ______________________ Company # ____________________________ Case Manager(s) ___________________________TN CM Registration #(s) ____________________ ____________________________ _____________________Closure Code __________ Date of RTW _________ Comments: ______________________________________________________________________________________________________________ LB-0377 (rev. 9/99)<<<<<<<<<********>>>>>>>>>>>>> 2DIAGNOSIS: SPINE Cervical Thorax Lumba r Miscellaneous Strain/Sprain 847.0 847.1 847.2 Burn(s)* ____.__HNP 722.0 722.11 722.10 Carpal Tunnel Syndrome 354.0DJD* ____.___ ____.___ ____.___ Inguinal Hernia 550.90Other* ____.___ ____.___ ____.___ Rotator Cuff Tear 726.10 Torn Meniscus (Knee) 836.0 Epicondylitis* ____.__ Other* ____.__*S pecify appropriate code(s) *S pecify appropriate code(s) EXTREMITIES: Foot Toe Ankle Knee Hip FingerStrain/Sprain 845.1 845.13 845.00 844.9 843.9 842.10Contusion 924.2 924.3 924.21 924.11 924.01 923.3Tendonitis 727.0 726.90 727.06 726.60 726.5 727.0DJD 715.0 715.07 715.07 715.08 715.05 715.04Dislocation 838.0 838.09 837.0 836.50 835.00 834.00Bursitis 726.7 726.70 726.70 726.69 726.5 726.4Fracture* ___._ ___.__ ___.__ ___.__ ___.__ ___.__Laceration* ___._ ___.__ ___.__ ___.__ ___.__ ___.__Amputation* ___._ ___.__ ___.__ ___.__ ___.__ ___.__Other* ___._ ___.__ ___.__ ___.__ ___.__ ___.__*Specify appropriate code(s) EXTREMITIES: Hand Wrist Forearm Elbow Arm Shoulder OtherStrain/Sprain 842.1 842.01 841.8 841.9 840.9 840.90 ___.__Contusion 923.2 923.21 923.10 923.11 923.9 923.00 ___.__Tendonitis 727.0 727.0 727.00 726.39 726.2 726.10 ___.__DJD 715.0 715.03 715.03 715.08 715.0 715.01 ___.__Dislocation 833.0 833.00 ___.__ 832.00 ___._ 831.00 ___.__Bursitis 726.4 726.33 726.10 ___.__Fracture* ___._ ___.__ ___.__ ___.__ ___._ ___.__ ___.__Laceration* ___._ ___.__ ___.__ ___.__ ___._ ___.__ ___.__Amputation* ___._ ___.__ ___.__ ___.__ ___._ ___.__ ___.__Other* ___._ ___.__ ___.__ ___.__ ___._ ___.__ ___.__*Specify appropriate code(s) PROCEDURES: CT MRI Othe r Miscellaneous Head 70450 70551 ______ ACL Reconstruction 27407C-Spine 72125 72141 ______ Arthrogram* ______T-S pine 72128 72146 ______ Arthroscopy Knee* ______L/S Spine 72131 72148 ______ Carpal Tunnel Release 64721Coccyx 72131 72196 ______ EMG Upper Extremity 95860Hip 73700 72196 ______ EMG Lower Extremity 95861Pelvis 72192 72196 ______ Fracture Repair* ______Femur 73700 73720 ______ Hernia Repair 49505Knee 73700 73721 ______ Laminectomy Cervical 63001Shoulder 73200 73220 ______ Laminectomy Lumbar 63005Chest 71250 71550 ______ Myelogram Cervical 72240Abdomen 74150 74181 ______ Myelogram Lumbar 72265 Rotator Cuff Repair 23410PHYSICAL THERAPY Yes No Other* ______ *S pecify appropriate code(s)