Patient #1 A Spouse $534,946.73

Transcription

1 Shock Loss Report MM & RX Combined PUNBR: 002 GRNBR: 248 Warning Amount: Over Amount: Incurred MM 1/1/2014 through 12/31/2016 PaidMM 1/1/2016 through 12/31/2016 Incurred RX 12/16/2015 through 12/31/2016 Emp SSN Cert # Emp Name Patient Name Patient Current Patient #1 A Spouse $534, N18.6 END STAGE RENAL DISEASE $214, I50.3 DIASTOLIC (CONGESTIVE) HEART FAILURE $138, A41.9 SEPSIS, UNSPECIFIED ORGANISM $94, I95.1 ORTHOSTATIC HYPOTENSION $37, $8, Patient #2 A Employee $457, A41.9 SEPSIS, UNSPECIFIED ORGANISM $219, I72.8 ANEURYSM OF OTHER SPECIFIED ARTERIES $84, M54.1 RADICULOPATHY $49, J96.0 ACUTE RESPIRATORY FAILURE $32, M50.1 CERVICAL DISC DISORDER WITH RADICULOPATHY $14, Patient #3 T Employee $288, A41.9 SEPSIS, UNSPECIFIED ORGANISM $266, G06.1 INTRASPINAL ABSCESS AND GRANULOMA $5, J96.0 ACUTE RESPIRATORY FAILURE $4, A41.0 SEPSIS DUE TO STAPHYLOCOCCUS AUREUS $2, $1, /27/ :11:15 PM Page 1

2 Patient #4 A Spouse $285, C92.4 ACUTE PROMYELOCYTIC LEUKEMIA $232, $12, K08.4 PARTIAL LOSS OF TEETH $9, A41.9 SEPSIS, UNSPECIFIED ORGANISM $9, R51 HEADACHE $6, Patient #5 A Son $263, H90.5 UNSPECIFIED SENSORINEURAL HEARING LOSS $141, L02.8 CUTANEOUS ABSCESS, FURUNCLE AND CARBUNCLE OF OTHER SITES $71, T85.7 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER INTERNAL $28, T81.4 INFECTION FOLLOWING A PROCEDURE $13, H90.3 SENSORINEURAL HEARING LOSS, BILATERAL $2, Patient #6 A Employee $249, C63.1 MALIGNANT NEOPLASM OF SPERMATIC CORD $124, Z51.1 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY AND $68, $18, R55 SYNCOPE AND COLLAPSE $12, J18.9 PNEUMONIA, UNSPECIFIED ORGANISM $8, Patient #7 R Employee $246, S82.8 OTHER FRACTURES OF LOWER LEG $233, $7, S91.0 OPEN WOUND OF ANKLE $1, S81.8 OPEN WOUND OF LOWER LEG $1, T07 UNSPECIFIED MULTIPLE INJURIES $ Patient #8 A Spouse $239, M19.0 PRIMARY OSTEOARTHRITIS OF OTHER JOINTS $166, T84.8 OTHER SPECIFIED COMPLICATIONS OF INTERNAL ORTHOPEDIC $22, T85.8 OTHER SPECIFIED COMPLICATIONS OF INTERNAL PROSTHETIC DEVICES, $14, S93.4 SPRAIN OF ANKLE $13, Page 2

3 $4, Patient #9 A Employee $222, I12.0 HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC $96, Z48.2 ENCOUNTER FOR AFTERCARE FOLLOWING ORGAN TRANSPLANT $43, T86.1 COMPLICATIONS OF KIDNEY TRANSPLANT $32, N18.6 END STAGE RENAL DISEASE $23, Z94.0 KIDNEY TRANSPLANT STATUS $7, Patient #10 A Spouse $191, T82.8 OTHER SPECIFIED COMPLICATIONS OF CARDIAC AND VASCULAR $101, I21.3 ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE $56, I11.0 HYPERTENSIVE HEART DISEASE WITH HEART FAILURE $10, $9, I21.0 ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF ANTERIOR WALL $7, Patient #11 A Spouse $190, C49.9 MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE, $38, Z51.1 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY AND $36, Z76.8 PERSONS ENCOUNTERING HEALTH SERVICES IN OTHER SPECIFIED $23, C79.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW $18, D70.8 OTHER NEUTROPENIA $12, Patient #12 A Son $174, Z48.2 ENCOUNTER FOR AFTERCARE FOLLOWING ORGAN TRANSPLANT $55, K50.9 CROHN'S DISEASE, UNSPECIFIED $33, T86.1 COMPLICATIONS OF KIDNEY TRANSPLANT $31, $19, I85.0 ESOPHAGEAL VARICES $11, Patient #13 A Employee $173, Page 3

4 C7A.0 MALIGNANT CARCINOID TUMORS $66, C7A.8 OTHER MALIGNANT NEUROENDOCRINE TUMORS $63, C7B.8 OTHER SECONDARY NEUROENDOCRINE TUMORS $18, C7B.0 SECONDARY CARCINOID TUMORS $11, $6, Patient #14 R Employee $159, A41.9 SEPSIS, UNSPECIFIED ORGANISM $144, J86.9 PYOTHORAX WITHOUT FISTULA $7, J96.0 ACUTE RESPIRATORY FAILURE $2, $2, R91.8 OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD $ Patient #15 A Spouse $158, $60, S72.1 PERTROCHANTERIC FRACTURE $51, E11.6 TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS $25, I25.1 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY $9, I95.9 HYPOTENSION, UNSPECIFIED $2, Patient #16 A Employee $158, M48.0 SPINAL STENOSIS $67, M43.1 SPONDYLOLISTHESIS $54, C50.4 MALIGNANT NEOPLASM OF UPPER OUTER QUADRANT OF BREAST $15, C50.8 MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BREAST $4, M54.1 RADICULOPATHY $4, Patient #17 A Spouse $146, M86.4 CHRONIC OSTEOMYELITIS WITH DRAINING SINUS $73, M86.1 OTHER ACUTE OSTEOMYELITIS $22, L03.1 CELLULITIS AND ACUTE LYMPHANGITIS OF OTHER PARTS OF LIMB $21, OTHER DERANGEMENT OF JOINT / CONTRACTURE OF JOINT $4, Page 4

5 $3, Patient #18 A Son $142, Q24.4 CONGENITAL SUBAORTIC STENOSIS $136, Q23.0 CONGENITAL STENOSIS OF AORTIC VALVE $2, I50.9 HEART FAILURE, UNSPECIFIED $1, Q24.2 COR TRIATRIATUM $ Q53.1 UNDESCENDED TESTICLE, UNILATERAL $ Patient #19 A Daughter $141, Z38.0 SINGLE LIVEBORN INFANT, BORN IN HOSPITAL $126, P22.0 RESPIRATORY DISTRESS SYNDROME OF NEWBORN $7, P07.1 OTHER LOW BIRTH WEIGHT NEWBORN $3, Q21.1 ATRIAL SEPTAL DEFECT $2, P28.4 OTHER APNEA OF NEWBORN $ Patient #20 A Spouse $139, I25.1 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY $111, Z98.6 ANGIOPLASTY STATUS $12, I25.8 OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE $3, Z01.8 ENCOUNTER FOR OTHER SPECIFIED SPECIAL EXAMINATIONS $2, I10 ESSENTIAL (PRIMARY) HYPERTENSION $1, Patient #21 A Employee $137, N18.6 END STAGE RENAL DISEASE $84, N17.9 ACUTE KIDNEY FAILURE, UNSPECIFIED $41, I12.0 HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC $7, R55 SYNCOPE AND COLLAPSE $1, $1, Patient #22 T Spouse $136, Page 5

6 M17.1 UNILATERAL PRIMARY OSTEOARTHRITIS OF KNEE $79, $39, M16.1 UNILATERAL PRIMARY OSTEOARTHRITIS OF HIP $4, H81.1 BENIGN PAROXYSMAL VERTIGO $3, G89.1 ACUTE PAIN, NOT ELSEWHERE CLASSIFIED $1, Patient #23 A Spouse $126, A41.9 SEPSIS, UNSPECIFIED ORGANISM $38, J44.1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) $30, I50.2 SYSTOLIC (CONGESTIVE) HEART FAILURE $15, $15, I42.0 DILATED CARDIOMYOPATHY $9, Patient #24 A Employee $123, I82.4 ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF LOWER $118, I26.9 PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE $1, $1, R07.9 CHEST PAIN, UNSPECIFIED $ R52 PAIN, UNSPECIFIED $ Patient #25 A Employee $120, C50.5 MALIGNANT NEOPLASM OF LOWER OUTER QUADRANT OF BREAST $49, Z51.0 ENCOUNTER FOR ANTINEOPLASTIC RADIATION THERAPY $31, Z51.1 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY AND $29, C50.9 MALIGNANT NEOPLASM OF BREAST OF UNSPECIFIED SITE $4, R07.9 CHEST PAIN, UNSPECIFIED $ Patient #26 A Spouse $116, N81.4 UTEROVAGINAL PROLAPSE, UNSPECIFIED $25, K95.0 COMPLICATIONS OF GASTRIC BAND PROCEDURE $22, M54.1 RADICULOPATHY $17, T85.5 MECHANICAL COMPLICATION OF GASTROINTESTINAL PROSTHETIC $12, Page 6

7 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT $12, Patient #27 T Daughter $115, Q42.2 CONGENITAL ABSENCE, ATRESIA AND STENOSIS OF ANUS WITH FISTULA $79, R06.8 OTHER ABNORMALITIES OF BREATHING $16, Z38.0 SINGLE LIVEBORN INFANT, BORN IN HOSPITAL $8, P28.8 OTHER SPECIFIED RESPIRATORY CONDITIONS OF NEWBORN $3, P08.1 OTHER HEAVY FOR GESTATIONAL AGE NEWBORN $2, Patient #28 A Daughter $104, G50.0 TRIGEMINAL NEURALGIA $81, TRIGEMINAL NERVE DISORDERS / TRIGEMINAL NEURALGIA $14, Z30.2 ENCOUNTER FOR STERILIZATION $3, G43.9 MIGRAINE, UNSPECIFIED $1, $1, Patient #29 R Employee $102, I35.0 NONRHEUMATIC AORTIC (VALVE) STENOSIS $88, K25.4 CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE $6, I35.2 NONRHEUMATIC AORTIC (VALVE) STENOSIS WITH INSUFFICIENCY $2, K92.2 GASTROINTESTINAL HEMORRHAGE, UNSPECIFIED $ R41.8 OTHER SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND $ Page 7

8 Shock Loss Report MM & RX Combined PUNBR: 002 GRNBR: 248 Warning Amount: Over Amount: Incurred MM 1/1/2015 through 12/31/2017 PaidMM 1/1/2017 through 12/31/2017 Incurred RX 12/16/2016 through 12/31/2017 Emp SSN Cert # Emp Name Patient Name Patient Current Patient #1 A Spouse $489, N18.6 END STAGE RENAL DISEASE L89.1 PRESSURE ULCER OF BACK T81.8 OTHER COMPLICATIONS OF PROCEDURES, NOT ELSEWHERE CLASSIFIED A41.9 SEPSIS, UNSPECIFIED ORGANISM Patient #2 A Daughter $463, G12.9 SPINAL MUSCULAR ATROPHY, UNSPECIFIED R51 HEADACHE G12.0 INFANTILE SPINAL MUSCULAR ATROPHY, TYPE I [WERDNIG HOFFMAN] G97.1 OTHER REACTION TO SPINAL AND LUMBAR PUNCTURE R09.0 ASPHYXIA AND HYPOXEMIA Patient #3 A Daughter $426, Z38.0 SINGLE LIVEBORN INFANT, BORN IN HOSPITAL P28.0 PRIMARY ATELECTASIS OF NEWBORN P28.8 OTHER SPECIFIED RESPIRATORY CONDITIONS OF NEWBORN Q25.0 PATENT DUCTUS ARTERIOSUS P22.0 RESPIRATORY DISTRESS SYNDROME OF NEWBORN $284, $119, $25, $24, $8, $397, $22, $16, $8, $5, $265, $67, $41, $22, $22, /27/ :10:07 PM Page 1

9 Patient #4 A Employee $360, N18.6 END STAGE RENAL DISEASE T85.6 MECHANICAL COMPLICATION OF OTHER SPECIFIED INTERNAL AND I12.0 HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC Z45.2 ENCOUNTER FOR ADJUSTMENT AND MANAGEMENT OF VASCULAR Patient #5 A Spouse $326, E11.6 TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS K22.1 ULCER OF ESOPHAGUS S52.1 FRACTURE OF UPPER END OF RADIUS T25.3 BURN OF THIRD DEGREE OF ANKLE AND FOOT Patient #6 R Employee $242, E11.6 TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS E11.5 TYPE 2 DIABETES MELLITUS WITH CIRCULATORY COMPLICATIONS T87.4 INFECTION OF AMPUTATION STUMP I96 GANGRENE, NOT ELSEWHERE CLASSIFIED S98.2 TRAUMATIC AMPUTATION OF TWO OR MORE LESSER TOES Patient #7 A Employee $232, Z51.1 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY AND C34.3 MALIGNANT NEOPLASM OF LOWER LOBE, BRONCHUS OR LUNG C34.9 MALIGNANT NEOPLASM OF UNSPECIFIED PART OF BRONCHUS OR R91.8 OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD C34.2 MALIGNANT NEOPLASM OF MIDDLE LOBE, BRONCHUS OR LUNG Patient #8 A Son $211, A02.1 SALMONELLA SEPSIS A02.2 LOCALIZED SALMONELLA INFECTIONS K92.1 MELENA G00.9 BACTERIAL MENINGITIS, UNSPECIFIED Z00.1 ENCOUNTER FOR NEWBORN, INFANT AND CHILD HEALTH $342, $15, $1, $ $ $83, $48, $43, $29, $27, $88, $52, $50, $12, $7, $121, $39, $31, $22, $7, $174, $19, $6, $3, $1, Page 2

10 Patient #9 A Spouse $196, M48.0 SPINAL STENOSIS G89.4 CHRONIC PAIN SYNDROME M96.1 POSTLAMINECTOMY SYNDROME, NOT ELSEWHERE CLASSIFIED M51.1 THORACIC, THORACOLUMBAR AND LUMBOSACRAL INTERVERTEBRAL Patient #10 A Employee $189, G06.0 INTRACRANIAL ABSCESS AND GRANULOMA G93.9 DISORDER OF BRAIN, UNSPECIFIED R51 HEADACHE M25.5 PAIN IN JOINT I82.4 ACUTE EMBOLISM AND THROMBOSIS OF DEEP VEINS OF LOWER Patient #11 A Employee $162, Diagnosis Code C7A.0 C7B.0 D3A.8 C7B.8 Diag MALIGNANT CARCINOID TUMORS SECONDARY CARCINOID TUMORS OTHER BENIGN NEUROENDOCRINE TUMORS OTHER SECONDARY NEUROENDOCRINE TUMORS Patient #12 A Employee $153, I71.2 THORACIC AORTIC ANEURYSM, WITHOUT RUPTURE Q27.8 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF PERIPHERAL I65.2 OCCLUSION AND STENOSIS OF CAROTID ARTERY Q20.3 DISCORDANT VENTRICULOARTERIAL CONNECTION K29.5 UNSPECIFIED CHRONIC GASTRITIS Patient #13 A Spouse $152, G40.5 EPILEPTIC SEIZURES RELATED TO EXTERNAL CAUSES Z51.8 ENCOUNTER FOR OTHER SPECIFIED AFTERCARE J96.0 ACUTE RESPIRATORY FAILURE A41.9 SEPSIS, UNSPECIFIED ORGANISM $110, $52, $10, $8, $3, $160, $12, $2, $2, $1, $51, $48, $24, $11, $9, $74, $57, $7, $3, $2, $127, $6, $4, $3, $2, Page 3

11 Patient #14 T Spouse $151, C67.9 MALIGNANT NEOPLASM OF BLADDER, UNSPECIFIED N17.0 ACUTE KIDNEY FAILURE WITH TUBULAR NECROSIS A41.9 SEPSIS, UNSPECIFIED ORGANISM N17.9 ACUTE KIDNEY FAILURE, UNSPECIFIED C67.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF BLADDER Patient #15 T Spouse $148, I70.2 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES I25.1 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY I20.8 OTHER FORMS OF ANGINA PECTORIS E11.6 TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS Patient #16 T Spouse $122, C56.9 MALIGNANT NEOPLASM OF UNSPECIFIED OVARY Z51.1 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY AND C48.2 MALIGNANT NEOPLASM OF PERITONEUM, UNSPECIFIED R10.8 OTHER ABDOMINAL PAIN C78.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND Patient #17 A Employee $118, M17.1 UNILATERAL PRIMARY OSTEOARTHRITIS OF KNEE G47.3 SLEEP APNEA G89.1 ACUTE PAIN, NOT ELSEWHERE CLASSIFIED E11.6 TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATIONS Patient #18 A Employee $114, M48.0 SPINAL STENOSIS M54.1 RADICULOPATHY M47.2 OTHER SPONDYLOSIS WITH RADICULOPATHY M54.9 DORSALGIA, UNSPECIFIED M43.1 SPONDYLOLISTHESIS $52, $33, $18, $12, $11, $105, $31, $8, $2, $ $22, $18, $15, $13, $7, $93, $11, $8, $2, $ $95, $9, $3, $1, $ Page 4

12 Patient #19 A Employee $110, M17.1 UNILATERAL PRIMARY OSTEOARTHRITIS OF KNEE Z47.1 AFTERCARE FOLLOWING JOINT REPLACEMENT SURGERY M25.3 OTHER INSTABILITY OF JOINT K42.9 UMBILICAL HERNIA WITHOUT OBSTRUCTION OR GANGRENE G89.1 ACUTE PAIN, NOT ELSEWHERE CLASSIFIED Patient #20 A Employee $109, M47.2 OTHER SPONDYLOSIS WITH RADICULOPATHY M UNKNOWN M54.1 RADICULOPATHY M51.2 OTHER THORACIC, THORACOLUMBAR AND LUMBOSACRAL Patient #21 R Employee $106, N18.6 END STAGE RENAL DISEASE Z01.8 ENCOUNTER FOR OTHER SPECIFIED SPECIAL EXAMINATIONS K60.2 ANAL FISSURE, UNSPECIFIED R50.9 FEVER, UNSPECIFIED Patient #22 A Spouse $106, M51.1 THORACIC, THORACOLUMBAR AND LUMBOSACRAL INTERVERTEBRAL I26.9 PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE M48.0 SPINAL STENOSIS M43.1 SPONDYLOLISTHESIS Patient #23 A Employee $104, M17.1 UNILATERAL PRIMARY OSTEOARTHRITIS OF KNEE G89.1 ACUTE PAIN, NOT ELSEWHERE CLASSIFIED G47.3 SLEEP APNEA R47.1 DYSARTHRIA AND ANARTHRIA $80, $7, $6, $4, $3, $45, $45, $4, $3, $2, $50, $26, $12, $6, $4, $57, $15, $14, $5, $5, $83, $15, $3, $ $ Page 5

13 Patient #24 A Employee $103, I47.2 VENTRICULAR TACHYCARDIA I25.1 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY R07.9 CHEST PAIN, UNSPECIFIED I21.3 ST ELEVATION (STEMI) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE R00.0 TACHYCARDIA, UNSPECIFIED Patient #25 A Daughter $100, G40.1 LOCALIZATION RELATED (FOCAL) (PARTIAL) SYMPTOMATIC EPILEPSY G80.8 OTHER CEREBRAL PALSY G47.3 SLEEP APNEA M24.5 CONTRACTURE OF JOINT G80.2 SPASTIC HEMIPLEGIC CEREBRAL PALSY $100, $1, $ $ $ $43, $18, $14, $7, $3, Page 6