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ICD-10 Phase Ⅰ Testing OB-GYN: Clinical Dx Scenarios INSTRUCTIONS Florida’s Blue Cross and Blue Shield Plan 1. Print this form in order to complete it by hand. 2. Complete your contact information at left of form. 3. Select up to five (5) scenarios below for practice coding. 4. Instruct your medical coder(s) to complete this document by coding your selected scenarios first using ICD-9 Dx codes followed by ICD10 Dx codes. Be sure coder(s) understand they are to code in ICD-10 from the selected clinical scenarios vs. coding from ICD-9 to ICD-10 (mapping). 5. Scan and return by email your completed form to ICD-10testing@ floridablue.com. If you do not have access to a scanner and would like to return your form to us via fax, please fax to 904-997-5571, Attn: Martina Fiorelli. 6. Within two weeks of receipt, Florida Blue will review your completed coding document and provide you with observations for scenarios that we have identified as a potential impact to claims adjudication. Your Name: Title: Practice/Organization Name: NPI Number: Email Address: Telephone #: Name of your system vendor, clearinghouse and/or billing service and contact data you may have for them: NOTE: If you prefer, you may contact Florida Blue via email ICD-10testing@ floridablue.com and you will be provided an Excel spreadsheet on which you can view and code these same scenarios. Email your completed form to us at [email protected] Note: It is critical to successful testing that we collaborate with both providers and their vendors who enable ICD-10 transactions for their clients. Scenario # Scenario Description S015 A 40-year-old female established patient comes into the office for a yearly physical. No current complaints or problems. No previous health complications. Physical examination is performed. Patient advised to continue yearly examinations including mammograms and pap smears. Also, patient is encouraged to continue a healthy diet and exercise regimen. Impression: Annual physical examination. S016 A 25-year-old female comes into the office for her yearly OB/GYN visit. Patient has concerns about birth control and would like to seek information from a health care professional. Vital signs, gynecological examination and labs were performed. Discussed birth control options and provided a 3-month trial supply of Trivora-28. Also, prescribed a 6-month supply of Trivora-28. Impression: Annual gynecological examination. S068 The patient is a 40-year-old healthy female who comes in today for annual physical exam. Patient history, medications and vital signs documented in the chart. Physician performed breast screening and pelvic exam. Patient advises she has been using aspirin to prevent stroke and heart attack. Physician ordered CBC, chemistry panel and urinalysis. Patient was given influenza vaccine in this visit. Follow up visit scheduled for review of lab results. Impressions: Prophylactic vaccination and inoculation, influenza and long term use of aspirin. 900-79573-0114_OBG 900-4261-0214 ICD-9 Code ICD-9 Description 1 of 2 ICD-10 Code ICD-10 Description Scenario # Scenario Description S077 A 36-year-old female patient comes to the office to discuss the results of her breast biopsy. Patient states she has a long-term use of oral contraceptives and a family history of breast cancer. The result of the biopsy indicates breast cancer, stage 3. Two treatment options were discussed, and they are: 1) lumpectomy followed by radiation therapy; and 2) mastectomy, with or without breast reconstruction, followed by radiation therapy and chemotherapy to destroy the potential for cancer cells to remain as well as prevent the breast cancer from recurring. The patient elected to undergo a mastectomy with breast reconstruction. Surgery was scheduled and she was referred to a plastic surgeon for the post-mastectomy reconstruction. Impression: Malignant neoplasm of the breast. S083 A 23-year-old female is rushed to the ED by her partner due to sudden symptoms of shock. She states that she had an elective abortion less than 48 hours ago and noticed that her vaginal bleeding has increased tremendously in the last 24 hours. She said she is using 1 large sanitary napkin per hour. Vital signs were taken. Physical exam performed. Diagnostic labs revealed abnormally low hemoglobin levels associated with blood loss. Intravenous fluids were started to stabilize vitals. Impression: Acute post-hemorrhagic anemia. 900-79573-0114_OBG 900-4261-0214 ICD-9 Code ICD-9 Description 2 of 2 ICD-10 Code ICD-10 Description