Demographic Information. Records on File as of March 29, Other Providers Referenced in the Records
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1 Case Caption Jane Doe - Personal Injury Job No Claim Number WCAB Number Demographic Information Claimant Jane Doe Date of Birth January 1, 1964 Date of Injury August 19, 2009 Social Security Number Gender Female Records on File as of March 29, 2012 Record Source Location Firm Work Order No. Pages Corazon Nurse Consultancy South Pasadena, CA Clara Clarita Rehab Center Los Angeles, CA Julio Don Pedro, MD Beverly Hills, CA Total Pages: 33 Other Providers Referenced in the Records Provider Location Request Records Twin Open Imaging Center Beverly Hills, CA Maggie Sew, MS Edward Cruz, MD Beverly Hills, CA Martin Nierras, MD Kevin Custom, MD Jacob Steinfeld, PhD Gabriel Fausto, MD Ken Otana, DC One Open MRI Studio Los Angeles, CA To request record summaries, contact us at (213) , or visit our website
2 Records of : Doe, Jane Job No. : ILLUSTRATED SUMMARY OF RECORDS Breakdown of Encounters Total = 23 Breakdown of Billing per Provider Total = $ 9,776 Illustrated Summary of Records Page 1 of 2
3 Breakdown of Encounters per Provider per Period Breakdown of Billing per Provider per Period Illustrated Summary of Records Page 2 of 2
4 Records of : Doe, Jane Job No. : RECORD INDEX Date Document Source Report Title Type of Encounter Page No. 5/21/2008 One Open MRI Studio Julie Don Juan, MD MRI of the Right Shoulder with Intra-Articular Gadolinium X-ray / Diagnostic Pg 1 12/14/2009 Twin Open Imaging Center Julie Don Diego, MD MRI of the Cervical Spine without Contrast X-ray / Diagnostic Pg /14/2009 Twin Open Imaging Center Julie Don Diego, MD MRI of the Lumbar Spine without Contrast X-ray / Diagnostic Pg /14/2009 Twin Open Imaging Center Julie Don Diego, MD MRI of the Right Knee without Contrast X-ray / Diagnostic Pg 30 3/4/2010 Julio Don Pedro, MD Initial Pain Management Consultation Initial Pg /24/2010 Julio Don Pedro, MD Operative Note Operative / Surgical Pg /23/2010 Julio Don Pedro, MD Supplementary Report Follow-up Pg /19/2010 to 10/21/2010 Clara Clarita Rehab Center June Don Carlo, RPT Clinical Care Notes Therapy / Acupuncture / Chiro Pg /13/2010 Corazon Nurse Consultancy Juana Don Martin, RN Notes on the Home Visit Home Visit Pg /7/2010 Corazon Nurse Consultancy Invoice Non-encounter Pg /30/2010 Clara Clarita Rehab Center Balance Sheet Non-encounter Pg 2-3 Record Index Page 1 of 1
5 Records of : Doe, Jane Job No. : RECORD SUMMARY 5/21/2008 MRI of the Right Shoulder with Intra- Articular Gadolinium Impression: Normal shoulder MRI. Julie Don Juan, MD One Open MRI Studio Los Angeles, CA Pg 1 12/14/2009 Julie Don Diego, MD Twin Open Imaging Center Beverly Hills, CA Pg 4-5 MRI of the Cervical Spine without Contrast Impression: 1) C3-C4: There is mild disc desiccation. There is a right paracentral 2-mm disc protrusion slightly indenting the anterior cord with mild spinal stenosis. There is no neural foraminal narrowing. 2) C4-C5: There is mild to moderate disc desiccation and disc space narrowing. There is right paracentral combination of spur and a 2mm disc protrusion indenting the anterior cord with mild to moderate spinal stenosis. There is no neural foraminal narrowing. 3) C5-C6: There is mild to moderate disc desiccation and disc space narrowing. There is mild broad based posterior spur with mild narrowing of the right side of the canal. There is mild to moderate right neural foraminal narrowing. There is no left neural foraminal narrowing. 4) C6-C7: There is mild to moderate disc desiccation. There is a 2-mm central broad based disc protrusion. There is no spinal stenosis or neural foraminal narrowing. 12/14/2009 Julie Don Diego, MD Twin Open Imaging Center Beverly Hills, CA Pg 8-9 MRI of the Lumbar Spine without Contrast Impression: 1) Hemisacralization of the L5 right transverse process with moderate endplate degenerative changes at L4-L5 level to the left of the midline and mild scoliosis of the lumbar spine. 2) L4-L5: There is moderate disc desiccation. There are mild to moderate bilateral facet degenerative changes. There is left paracentral and left neural foraminal 4-5 mm broad based disc protrusion. There is also focus of annular fissure. There is no spinal stenosis. There is mild right neural foraminal narrowing. There is moderate to severe left neural foraminal narrowing. There are moderate degenerative endplate changes to the left of the midline. 3) L2-L3: There is mild disc desiccation. There are mild facet degenerative changes and ligamentum flavum hypertrophy. There is central left paracentral and left neural foraminal 3mm broad based disc protrusion and small focus of annular fissure. There is no spinal stenosis. There is mild left lateral recess and left Record Summary Page 1 of 4
6 neural foraminal narrowing. 4) L3-L4: There is mild disc desiccation. There are mild facet degenerative changes. There are moderate degenerative endplate changes. There is a 3-mm broad based posterior disc bulge and focus of annular fissure. There is no spinal stenosis. There is mild bilateral lateral recess and neural foraminal narrowing. 12/14/2009 MRI of the Right Knee without Contrast Julie Don Diego, MD Twin Open Imaging Center Beverly Hills, CA Impression: 1) Tear of the posterior horn of the medial meniscus. 2) Meniscal cyst posteromedially. Pg 30 3/4/2010 Initial Pain Management Consultation Julio Don Pedro, MD Beverly Hills, CA Chief Complaints: 1) Pain with right upper extremity radiating symptoms and weakness. 2) Low back pain with left lower extremity radiating pain. 3) Right knee pain and swelling. Pg History of Injury: In 8/09, the patient was driving when another vehicle hit the driver side of her vehicle. On impact, she was jolted forcefully. Her right knee struck the dashboard and she sustained a jarring injury to her neck. Medical History: She had a slip-and-fall injury in 2007 in a dentist s office. She injured her neck and low back, and dislocated her right shoulder. She related she had a cardiac arrest during her right shoulder surgery. Diagnostic Impressions: 1) Right cervical radiculopathy. 2) Left lumbar radiculopathy with L4-5 disc disruption. 3) Right knee internal derangement. 4) Multilevel lumbar spondylosis. 5) Multilevel cervical spondylosis. 6) History of congenital scoliosis. 7) Smoker. Plan: 1) Authorization request for cervical epidural steroid injection to the right C5-6 nerve. 2) Authorization request for left L5 transforaminal epidural steroid injection. 3) Remain under the care of Dr. Tauber for right knee internal derangement. 4) Medications include Flector patch, Skelaxin, and Amrix. 5) It is medically probable that she will require spine surgical consultation. 3/24/2010 Operative Note Julio Don Pedro, MD Beverly Hills, CA Preoperative and Postoperative Diagnosis: Right cervical radiculopathy. Procedures performed: 1) Cervical interlaminar epidural. 2) Cervical epidural with catheter placement. 3) Cervical epidural steroid. Pg Record Summary Page 2 of 4
7 4) Cervical epidurogram with interpretation. 4/23/2010 Julio Don Pedro, MD Beverly Hills, CA Pg Supplementary Report The patient continued to have severe lumbar & cervical spine pain complaints. She had completed cervical interlaminar epidural injections with some improvement in neck pain and ROM with decreased stiffness. The lumbar transforaminal epidural injection provided no benefit. She continued with severe back pain and bilateral radiating symptoms. Diagnostic impression: 1) Right cervical radiculopathy. Improved following cervical epidural. 2) Bilateral lumbar radiculopathy radiculopathy with multilevel disc disruption. 3) Right knee internal derangement. 4) Multilevel lumbar spondylosis. 5) Multilevel cervical spondylosis. 6) History of congenital scoliosis. She had more benefit with interlaminar cervical epidural than from the bilateral L5-S1 selective transforaminal epidural. She continued with radicular pain in both legs. Plan: 1) Authorization request for trial of lumbar interlaminar epidural at L4-5. 2) Medication management: Darvocet and Soma. 3) Continue conservative treatment. 8/19/2010 to 10/21/2010 June Don Carlo, RPT Clara Clarita Rehab Center Los Angeles, CA Pg Clinical Care Notes The patient was seen a total of 15 times. She reported that her right shoulder was sore and painful. On 9/28/10, she complained of pain in the right cervical spine radiating to the right upper extremity. On 10/5/10, she reported sinus infection causing her right eye to tear up. On 10/21/10, she requested HP with electrical stimulation to the right upper extremity/shoulder. 10/13/2010 Juana Don Martin, RN Corazon Nurse Consultancy South Pasadena, CA Pg Notes on the Home Visit The patient complained of low back & right shoulder problems stemming from a slip-andfall injury. She described an MVA in 8/09, wherein she injured her cervical spine and aggravated her lumbar injury. She reported a prior broken nose and underwent a rhinoplasty. She has a history of depression. She was treated for smoking cessation using bupropion. Her physicians included Dr. Jacob Tauber, Scott Onada, DC, Dr. Kevin Aminian, Dr. Kamran Matin and Dr. Lawrence Miller. Record Summary Page 3 of 4
8 She also complained of increased difficulty finishing tasks at work, difficulty hearing, sleep problems, SOB, weight loss, right knee pain & weakness, fatigue, anxiety, stress, and tendency to worry. 12/7/2010 Invoice Refer to the Billing Review. Corazon Nurse Consultancy South Pasadena, CA Pg /30/2010 Balance Sheet Refer to the Billing Review. Clara Clarita Rehab Center Los Angeles, CA Pg 2-3 Record Summary Page 4 of 4
9 Records of : Doe, Jane Job No. : BILLING REVIEW Provider: Clara Clarita Rehab Center Total Charges: $ 3, Total Payments: $ - Location: Los Angeles, CA Total Adjustments: $ - Date of Service: 8/19/2010 to 10/21/2010 Outstanding Balance: $ 3, DOS ICD9 CPT Description Charges Daily Total Payments Insurance Patient Other sources Write-off / Adjustment / Discount Billing Record Page No Medical Record Page No. 8/19/ Initial Eval (PI & PVT only) Pg 2 Pg 31 8/24/ Myofascial Release Soft Tissue Pg 2 Pg Init 30 min Therapy, Exercise Pg Indiv Instruction (Home Exercise) Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg Exercise Pamphlets Pg Electrodes 4" Pg 2 8/26/ Myofascial Release Soft Tissue Pg 2 Pg Init 30 min Therapy, Exercise Pg Electrical Stimulation Pg Vasopneumatic Devices Pg Taping Pg Hot / Cold Packs (PVT & PIT only) Pg Kinesiotape Pg 2 8/31/ Myofascial Release Soft Tissue Pg 2 Pg Init 30 min Therapy, Exercise Pg Electrical Stimulation Pg Vasopneumatic Devices Pg Taping Pg Hot / Cold Packs (PVT & PIT only) Pg Kinesiotape Pg 2 9/3/ Init 30 min Therapy, Exercise Pg 2 Pg Myofascial Release Soft Tissue Pg 2 9/7/ Init 30 min Therapy, Exercise Pg 2 Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg 2 9/9/ Myofascial Release Soft Tissue Pg 2 Pg Init 30 min Therapy, Exercise Pg 2 9/21/ Myofascial Release Soft Tissue Pg 2 Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg 2 9/23/ Re-Evaluation (PI & PVT only) Pg 2 Pg Indiv Instruction (Home Exercise) Pg Hot / Cold Packs (PVT & PIT only) Pg Mechanical Traction Pg Electrical Stimulation Pg Exercise Pamphlets Pg Theraband Pg 3 9/28/ Myofascial Release Soft Tissue Pg 3 Pg Init 30 min Therapy, Exercise Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg 3 9/30/ Init 30 min Therapy, Exercise Pg 3 Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg 3 10/5/ Myofascial Release Soft Tissue Pg 3 Pg Init 30 min Therapy, Exercise Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg 3 Billing Review Clara Clarita Rehab Center Page 1 of 2
10 Payments DOS ICD9 CPT Description Charges Daily Total Insurance Patient Other sources Write-off / Adjustment / Discount Billing Record Page No Medical Record Page No. 10/12/ Init 30 min Therapy, Exercise Pg 3 Pg Hot / Cold Packs (PVT & PIT only) Pg Mechanical Traction Pg Electrical Stimulation Pg 3 10/19/ Myofascial Release Soft Tissue Pg 3 Pg Init 30 min Therapy, Exercise Pg Hot / Cold Packs (PVT & PIT only) Pg Electrical Stimulation Pg 3 10/21/ Hot / Cold Packs (PVT & PIT only) Pg 3 Pg Electrical Stimulation Pg 3 TOTAL 3, Billing Review Clara Clarita Rehab Center Page 2 of 2
11 Records of : Doe, Jane Job No. : BILLING REVIEW Provider: Corazon Nurse Consultancy Total Charges: $ 6, Juana Don Martin, RN Total Payments: $ 2, Location: South Pasadena, CA Total Adjustments: $ - Date of Service: 9/20/2010 to 12/7/2010 Outstanding Balance: $ 4, DOS ICD9 CPT Description Charges Daily Total Payments Insurance Patient Other sources Write-off / Adjustment / Discount Billing Record Page No Medical Record Page No. 9/20/2010 Case Referred - - Pg 6 Retainer Letter - Pg 6 10/1/2010 Called Client Pg 6 10/13/2010 Medical Records Review Pg 6 Home Visit Pg 6 Pg 24 Travel Time Pg 6 Mileage 9.00 Pg 6 10/16/2010 Home Visit Notes , Pg 6 Pg 24 Records Review Pg 6 10/18/2010 Conversation with Client Pg 6 10/20/2010 LCP Pg 6 10/25/2010 Called Dr. Steinquist - left msg. - - Pg 6 10/26/2010 Called Geri Knorr - left msg - - Pg 6 10/29/2010 Called Dr. Steinquist - left msg. - - Pg 6 Called Dr. Tauber's office - Pg 6 11/2/2010 Conversation with Geri Knorr Pg 6 Spoke with Dr. Steinquist Pg 6 11/11/2010 Additional Records Review Pg 6 11/13/2010 Discussion with atty Pg 6 Life Care Plan (LCP) Pg 6 11/16/2010 Called Dr. Aminian's office - - Pg 6 11/21/2010 Called Dr. Steinquist Pg 6 LCP Pg 6 11/22/2010 Fax to Dr. Aminian Pg 6 Records Review Pg 6 11/23/2010 Called Dr. Tauber's office - - Pg 6 11/29/2010 LCP Pg 6 Fax to Dr. Tauber - Pg 6 Spoke with Dr. Aminian Pg 6 11/30/2010 Teleconference with Dr. Tauber Pg 6 12/1/2010 LCP 1, , Pg 7 12/7/2010 LCP & Cost Projection Pg 7 Retainer Received 2, Pg 7 TOTAL 6, , Billing Review Corazon Nurse Consultancy Page 1 of 1
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