Orville Wright designed, built and tested the world’s first aircraft engine in six weeks. No manufacturers were willing to build Wright’s engine, so he built it himself. Four cylinders, 12 horses and 200 pounds later, he placed the new engine into Flyer, the world’s first biplane. The rest is history.
Likewise, the healthcare industry is fast approaching one of its greatest milestones — the transition to the ICD-10 code set. The move to ICD-10 signifies the largest financial system change since establishment of the Prospective Payment System (PPS) in 1983. However, unlike Mr. Wright, we have solid roadmaps to help build, design and test our invention.
CMS, CDC, AHIMA, AHA, HIMSS and WEDI have all created tools to smooth the transition from ICD-9 to ICD-10. Timelines, guidelines, protocols and testing scenarios are readily available. With only 12 months remaining until the October 1, 2014, deadline, now is the time for every stakeholder in the healthcare revenue cycle to take a test flight.
Two Options for End-to-End Testing
There are two methods for testing ICD-10 claims transactions. The first uses real-world, standard case scenarios coded in ICD-10, while the second applies General Equivalency Mappings (GEMS) to existing ICD-9 claims. This article explains both.
Real-World Case Scenarios for Collaborative Testing
Nate Silver, an American statistician and author, states, “There’s no substitute for testing yourself on real-world situations that you don’t know the answer to in advance.” Silver, famous for his baseball and political predictions, has a point. Real-world case scenarios deliver a powerful punch of insight. Actual, de-identified medical records are the foundation for the ICD-10 National Testing Program (NTP).
Cases were hand-coded, vetted by clinical coding experts, and are now available for hospitals to use within their end-to-end testing initiatives. The NTP is an offshoot of the initial HIMSS/WEDI National Testing Pilot, which concluded in July 2013. HIMSS is currently underway with its ICD-10 National Pilot Program, and plans to release its updated ICD-10 PlayBook in the Fall of 2013.
While the HIMSS/WEDI National Testing Pilot and the NTP represent two separate projects, they are based on the same methodology: Use real-world, hand-coded cases as the optimal foundation for asynchronous, end-to-end testing among healthcare’s ICD-10 trading partners. Vendors, hospitals, providers, clearinghouses and payers all test using the same set of cases, while a central hub maintains communications and shares results between parties upstream and downstream in the revenue cycle.
Hospitals that use asynchronous, end-to-end testing based on real-world scenarios are able to:
- Identify true ICD-10 financial and operational impact;
- Assess their unique set of clinical documentation and coder skills to uncover gaps and fine-tune training programs; and
- Reduce testing costs through shared test cases and a central communication hub.
General Equivalence Mappings (GEMS)
GEMS is another ICD-10 testing methodology. Many healthcare payers state they will use GEMS for their baseline mapping system and ICD-10 testing. Providers are also using GEMS to estimate their general financial impact. (GEMS information is available via the CMS website, which is free to all healthcare stakeholders.)
The problem with GEMS is that more than 20 percent of Medicare codes in ICD-9 do not map to codes in ICD-10-CM/PCS. Furthermore, GEMS can be disabled and maps can be added to “fit” each payer’s unique rules. GEMS can help organizations estimate the financial and operational impact of ICD-10, but they are less effective in identifying specific clinical documentation and coding weaknesses.
Four best-practice tips to begin end-to-end testing initiatives:
- Discuss mapping methodologies with your payers now.
- Connect with regional peers and join local collaboratives to fully understand each payer’s unique ICD-10 plans.
- Implement dual coding as the first step in end-to-end testing.
- Test what you can now, and expand outward from there—even if you must convert claims to paper or test only a few claims processing steps at a time.
Ready. Set. Test.
Valentino Rossi, one of the most successful motorcycle racers of all time, states “Once the races begin it’s more difficult, and there is never that much time for testing.” End-to-end testing between providers, payers and clearinghouses identifies documentation weaknesses and points of technology integration failure for ICD-10 claims processing.
Early testing ensures that all parties have the opportunity to shore up their people, processes and technology to mitigate claims denials and reduce revenue loss with ICD-10. Whether your organization likens preparations for ICD-10 to motorcycle races or first flights, end-to-end testing will ensure your team doesn’t crash and burn come October 1, 2014.