FORM C-34 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002 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 Address: ____________________________________________________________________________ Insurer Claim #: ____________________________ Policy Number: _____________________________ Physician(s) Last Name First Name MD/DO/Chiro License# 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 Management Open __________________ Date Case Closed ___________________ Total Cost of Case Management _________________________________________________________ Medical Savings $_______________ How Saved: ___________ Negotiated provider/facility 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 Provider ______________________ Company # ____________________________ Case Manager(s) ______________________________ TN CM Registration #(s) _________________ _______________________________ ____________________________ Closure Code _________________________________ Date of RTW __________________________ Comments: ________________________________________________________________________ LB-0377 (REV. 12/07) 1 RDA 10183. American LegalNet, Inc. www.FormsWorkflow.com FORM C-34 DIAGNOSIS: SPINE Strain/Sprain HNP DJD* Other* Cervical 847.0 722.0 ____.___ ____.___ Thorax 847.1 722.11 ____.___ ____.___ Lumbar 847.2 722.10 ____.___ ____.___ Miscellaneous Burn(s)* Carpal Tunnel Syndrome Inguinal Hernia Rotator Cuff Tear Torn Meniscus (Knee) Epicondylitis* Other* *Specify appropriate code(s) *Specify appropriate code(s) ____.__ 354.0 550.90 726.10 836.0 ____.__ ____.__ EXTREMITIES: Strain/Sprain Contusion Tendonitis DJD Dislocation Bursitis Fracture* Laceration* Amputation* Other* *Specify appropriate code(s) Foot 845.10 924.20 727.06 715.07 838.00 726.70 ___.__ ___.__ ___.__ ___.__ Toe 845.13 924.3 726.90 715.07 838.09 726.70 ___.__ ___.__ ___.__ ___.__ Ankle 845.00 924.21 727.06 715.07 837.0 726.70 ___.__ ___.__ ___.__ ___.__ Knee 844.9 924.11 726.60 715.08 836.50 726.69 ___.__ ___.__ ___.__ ___.__ Hip 843.9 924.01 726.5 715.05 835.00 726.5 ___.__ ___.__ ___.__ ___.__ Finger 842.10 923.3 727.0 715.04 834.00 726.4 ___.__ ___.__ ___.__ ___.__ EXTREMITIES: Hand 842.10 923.20 727.00 715.04 833.00 Strain/Sprain Contusion Tendonitis DJD Dislocation Bursitis Fracture* ___.__ Laceration* ___.__ Amputation* ___.__ Other* ___.__ *Specify appropriate code(s) PROCEDURES: CT Scan Head 70450 FORM C-Spine 72125 T-Spine 72128 L/S Spine 72131 Coccyx 72131 Hip 73700 Pelvis 72192 Femur 73700 Knee 73700 Shoulder 73200 Chest 71250 Abdomen 74150 PHYSICAL LB-0377 (REV. 12/07) Yes Wrist 842.01 923.21 727.0 715.03 833.00 726.4 ___.__ ___.__ ___.__ ___.__ Forearm 841.8 923.10 727.00 715.03 ___.__ ___.__ ___.__ ___.__ ___.__ MRI 70551 72141 72146 72148 72196 72196 72196 73720 73721 73220 71550 74181 Other ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ No 2 Elbow 841.9 923.11 726.39 715.08 832.00 726.33 ___.__ ___.__ ___.__ ___.__ Arm 840.9 923.9 726.2 715.02 ___.__ ___.__ ___.__ ___.__ ___.__ Shoulder 840.90 923.00 726.10 715.01 831.00 726.10 ___.__ ___.__ ___.__ ___.__ Miscellaneous ACL Reconstruction Arthrogram* Arthroscopy Knee* Carpal Tunnel Release EMG Upper Extremity EMG Lower Extremity Fracture Repair* Hernia Repair Laminectomy Cervical Laminectomy Lumbar Myelogram Cervical Myelogram Lumbar Rotator Cuff Repair Other* *Specify appropriate code(s) Other ___.__ ___.__ ___.__ ___.__ ___.__ ___.__ ___.__ ___.__ ___.__ ___.__ 27407 ______ ______ 64721 95860 95861 ______ 49505 63001 63005 72240 72265 23410 ______ RDA 10183 American LegalNet, Inc. www.FormsWorkflow.com