The ICD-10 Journey

ICD-10 testing is about knowing the answers.

By Patrick McNeese for Advance for Health Information Professionals
There’s an old maxim that says: “Lawyers should never ask a Georgia grandma a question if they aren’t prepared for the answer.” ICD-10 testing needs to support that truism. Prior to development of test scenarios and scripts, an understanding of what to expect is absolutely required. At minimum, that means we need to understand:

Workflows – What is happening in the environment today where an ICD-9 diagnosis or procedure code is used? We know they are everywhere but how are they supported today? Testing has to mirror current business process models.

Project Plans – Testing will be an extensive and immersive activity and one that cannot be run “by the seat of your pants.” It is imperative that a structured, time-boxed approach be developed, maintained and monitored to have any potential for success.

Data – Know where the data is today. Where is the best information source for the generation of test claims? How can data be extracted to identify high-risk diagnosis and procedure codes? Where is DRG information housed and maintained? If claims editing software is employed, how can that data be incorporated into testing scenarios and scripts?

Once an overarching understanding has been reached, it’s time to delve into functional aspects of developing a testing approach. ICD-10 testing can be viewed over four domains:

1. System – At the highest level, are all internal automated applications/processes ICD-10 compliant? This compliance would include all internal and external interfaces as well.

2. Internal – Do internal business processes/transactions maintain integrity and intent when transitioned to an ICD-10 environment? Can transformations or translation be maintained, monitored, and audited? A strong caveat is in order here.the natural tendency will be to convert existing ICD-9 claims to ICD-10 using some type of crosswalk. This conversion can work for rudimentary test scenarios, but it is strongly recommended that some number of ICD-10 claims be generated natively from the clinical record. Only by seeing how a claim might actually be submitted and adjudicated will we see differences in key areas like reimbursement methodology. Often overlooked in the development of a testing approach are key metrics an organization may have associated with diagnosis or procedure codes. Do not forget reporting — an approach will be required to test all internal and external reporting requirements.

3. External – Find partners. Clearinghouses, payers and providers will have to partner to insure successful testing. Testing must incorporate both inbound and outbound transactions. Determine if fully parallel testing methodologies will be required to support the demands of testing and ongoing business processes.

4. End to End – The Centers for Medicare & Medicaid Services (CMS) has engaged in an end-to-end ICD-10 testing project that has widespread industry participation and support. Reviewing and incorporating the output from the project will serve as a strong baseline for developing end-to end scenarios and plans. Details on the CMS project are available at http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html.

Once prepared for the answers, the questions can be asked. Then the journey down the long road that is ICD-10 can begin.