Healthcare IT: ICD-10
It is mandatory for the medical practices to test the new ICD-10 procedures and tools to determine their workability sometime before the 1st of October.
The underlying goals include:
- Verification of the ability of medical practices to process, submit and receive data that contains ICD-10 codes.
- Developing a good understanding of the effects that payer policies and clearinghouses have on transactions.
- Identification of specific problems and then addressing them accordingly.
The AMA (American Medical Association) makes the process of testing simpler. It tests different transactions that you might have with your trading partners in order to see if the ICD-10 codes are being transmitted in a proper manner and can be interpreted by the systems you employ. The association also reviews the results of the test from your trading partners and tries to address any problems that have been identified during the testing process.
This doesn’t prove to be very helpful in real life. In such an instance, help is taken from the CMS (Centres for Medicare and Medicaid Services)
In order to start testing, it is necessary that the test cases are applicable in the real world.
- To begin identification of the different test scenarios that are possible, there is a need to separate the ICD-9 codes that are frequently used by you. These can be determined through system reports, superbills, common codes and encounter forms.
- You will then need to come up with a minimum of 10 encounters or claims that are already present and make use of the ICD-9 codes that you identified in the step before this one.
- Use the encounters that you identified in step 2, to come up with test cases. The ICD-9 codes identified can be used to pick out the ICD-10 codes that are relevant for each case. During this process, you can refer to the following:
- ICD-10 search tools and applications that are available online
- Common codes that are present in the action plan
- Crosswalks from your large payers and system vendors
- The ICD-10 CM codes of 2014 that have been released in tabular form
- Publications in any form, of the ICD-10 codes for 2014
- The GEMS (General Equivalence Mappings) Diagnosis Codes and Guide for 2014.
Mappings or crosswalks should only be used for reference. Natively, it is best to make use of the ICD-10 codes. This will help in the selection of specific codes that will be able to reflect the complex situation of patient car in a better manner.
- Your test cases should be designed for the inclusion of different dates of service. You can make use of ICD-10 codes to make simulations of service dates after the 1st of October 2014. You should try to make use of ICD-9 codes for at least one case and use that code for the simulation of a service date on or after 1st October 2014. This case will not be successful since the requirement of the ICD-10 codes is mandatory with dates of service on 1st October 2014 or after that. Also try the alternative of applying in ICD-10 code to a service date before 1st October 2014. This test will also fail because ICD-9 codes are required before the date mentioned.
You can validate your transactions with payers and vendors by running external tests for transactions that contain the ICD-10 codes to see if data is being transmitted successfully.
You need to make the stakeholder, on whom you’re conducting the tests, your priority. You should select payers and vendors who generate the largest impact on your revenues. You also need to select a time to test each payer and vendor accordingly.
You will then need to submit the data of your tests to the bill service, payer(s) and clearinghouse. Use your test cases to submit data to your payers or vendors. This can be done electronically if you have the means of doing so. If your system isn’t capable of sending test transactions electronically, use a manual way of sending the data such as paper, entry on websites or spreadsheets.
The clearing houses and the billing services should use your submitted data to create the electronic test transactions and send this to your chosen payers on your behalf. After the processing of transactions, the test results will be forwarded to you.
You should even take into consideration direct testing with your payers in situations where transactions and claims are submitted to payers directly. This can also be the case when your billing service or clearinghouse cannot guarantee its compliance with ICD-10 codes or if they are not ready to test with you. By using the direct method, you tend to negate risk to a large extent.
After this, it is time to review the results of the data that was submitted to the billing service, payer(s) or clearing houses. You will need to verify all the results with respect to claims, remittances, authorizations, eligibility and quality, for each transaction. Accuracy of the results needs to be checked. Denials, rejections and payments need to be examined to determine the main reason behind the rejections and denials and the difference in actual claim payments against what you expected. The results should be reviewed with payers and vendors to get answers to your queries and to understand the rules that are applicable to this situation.
You will also need to revise documents and billing processed in order to cope with the payment errors, denials and rejections later on too.
Your test data should be submitted to disease registries, health organizations, government agencies and hospitals as well. These are stakeholders and data should be exchanged with them. You can send the data electronically or manually as mentioned earlier.
You will then need to review the results of your test data that you sent to these organizations. You need to see if these entities are able to accept the ICD-10 data that was submitted by you. You need to see if you are also capable of processing the ICD-10 codes you receive from them. Work together with these entities to address any concerns.