ICD‐10: What is End‐to‐End Testing?

ICD‐10: What is End‐to‐End Testing? (edited)

Holly Louie, RN, CHBME, PCS & the HBMA ICD‐10 Committee | June 26, 2013
The gravity of undertaking a complete replacement of one of the essential elements of the healthcare reimbursement mechanism cannot be overstated: if the ICD‐10 CM implementation is executed flawlessly, there will be little difference between “before” & “after;” if there are problems, the impact will range from painful to cataclysmic.
Changing the way we code, process, & adjudicate medical claims is effectively altering the payment model, which could play havoc with the healthcare industry at large. We must learn from the mistakes that were made in transitioning from 4010 to 5010 & undertake the transition from ICD‐9 CM to ICD‐10 CM in a way that demonstrates we learned those lessons.
Among the shortcomings in the 5010 transition was the lack of a standard definition of what it meant to be “5010 ready.” What we subsequently learned was that every entity in the claims processing chain had a different definition of what they meant by the term “ready.” We believe it is not possible to be “ready” until meaningful, end‐to‐end testing has been successfully accomplished.
Also learned from the 5010 conversions was payor testing was severely limited. The first six months of 2012 underscored this point: many payors only tested syntax prior to the implementation of 5010, & in many cases, the scope of testing did not adequately cover the true edits. Additionally, their preparation did not provide for end‐to‐end testing with full claim‐level adjudication & remittances as part of the test.
As we all know, ICD‐10 CM will have far more impact & significantly greater change than 5010. Unlike 5010, physicians must be personally & actively involved in the ICD‐10 CM process. Unless the “lessons learned” from 5010 materially inform & affect the implementation of ICD‐10 CM, the economic stability of America’s healthcare reimbursement systems will be at risk & could be severely compromised.
In relative terms, adoption & implementation of 5010 was simple compared to the much greater magnitude of ICD‐10 CM. Every vendor system that stores, uses, depends on, transmits, or receives an ICD code, for whatever purpose, must modify some component of their practice management (PM) software to accommodate ICD‐10 CM. In the process, each vendor is forced to make decisions & set rules or policies regarding how they will treat ICD‐10 CM codes & handle the transition from ICD‐9 CM to ICD‐10 CM. While some elements of the modifications necessary to prepare for ICD‐10 CM have been addressed by many vendors, payors, & clearinghouses during the transition from ANSI 4010A1 to ANSI X12 5010A1, an enormous amount of work remains to be done.
If data cannot get to its intended location in the proper form & be received & interpreted in that established form, then submission of claims – certainly “clean” claims – that would result in appropriate payment can be interrupted. Innumerable interfaces exist because there are various approaches that the “owners” of each type of system can take when setting policies for handling data interchanges that involve ICD codes. Some owners may choose to use the General Equivalence Mappings (GEMs), proprietary translation tools, or other methodologies. Others may choose to extend maintenance & support of both ICD‐9 CM & ICD‐9 CM tables well beyond the final implementation date for ICD‐10 CM. In fact, HIPAA‐exempt insurers such as an automobile, tort, & workers compensation plans may continue to utilize ICD‐9 CM for years to come.
Because there are at least two entities involved in each interface, there must be ample time allowed for communication & the necessary development/modifications between every data trading instance to handle the specifics of each interface. The process of building these communications & translations between the interfaces will be very time & resource consuming, & failure to establish them properly could create chaos in the healthcare world. Providers & billers could be rendered incapable of functioning if these are not considered along with sufficient time provided for their development by October 1, 2014.
While the transport aspects of the ICD‐10 CM processing have, for the most part, been achieved, many – if not all – electronic data interchange/clearinghouse vendors will need adequate time to incorporate updates to their data validation or edit systems. This includes code validation, date validation, medical necessity validation, correct coding initiatives, & all published & promulgated payor rules based on diagnosis & procedure coding.
One of the lessons learned during the 5010 conversions was that adequate notification of the coding edits will be necessary to ensure successful testing between feeder systems (PMS & HIS) & the electronic data interchange/clearinghouse systems, as well as any contemplated testing between payors & providers. We know CMS heard this message & has established a workgroup of collaborating industry partners tasked with the establishment of benchmarks that cannot be ignored to assess the status of “ready” & “end‐to‐end” testing for the healthcare industry.
Finally, it is likely that some payor systems will not be able to process true ICD‐10 CM codes at the point at which the ICD‐10 CM goes into effect. Some payors have acknowledged that they will convert ICD‐10 CM into ICD‐9 CM with crosswalks for adjudication purposes, & that some type of conversion will take place when providing electronic remittance transactions back to the providers. This will result in providers needing information to determine if payments are in accordance with contracted agreements between providers & payors