By Wendy Coplan-Gould, RHIA

Although information technology (IT) professionals must install and test software upgrades for ICD-10, the true barometer of whether an organization will be ready for the transition occurs when providers successfully perform end-to-end testing – a full circle approach that requires significant collaboration between IT and Health information management (HIM).

End-to-end testing happens when providers send claims externally to payers and clearinghouses. These payers and clearinghouses then receive and process the claims. As part of the testing, providers must, in response, be able to receive any denials and post payments for those claims. If not already underway, testing with as many payers as possible should commence before the end of the first quarter of 2014. In fact, the Centers for Medicare & Medicaid Services (CMS) has designated the week of March 3-7 as front-end ICD-10 testing week between MACs and their trading partners.

Why HIM?
HIM skills and coding know-how are integral to the testing process to ensure accurate mapping and coding quality, as well as correct interpretation of testing results. Testing requires data integrity and accurate testing requires accurate data. When testing, providers cannot rely on General Equivalence Mappings (GEMs)and crosswalks. In fact, more than 20 percent of Medicare codes in ICD-9-CM do not map to codes in ICD-10-CM/PCS. Accurate data for ICD-10 testing comes from hand-coded cases in ICD-10.

HIM professionals must be involved in end-to-end testing for ICD-10. Following are the five tasks that HIM must help perform during the first quarter of 2014 to ensure robust and comprehensive testing prior to the October 1, 2014 implementation deadline.

#1: Identify all third-party entities with which testing must take place. Ideally, providers will test with each and every entity with which they exchange coded data. HIM professionals can get the ball rolling by compiling a list of all payers and other entities that will require ICD-10 code submission.

Contact these entities to determine if and when they will be testing with providers. Most payers are willing to conduct ICD-10 testing with providers that can send ICD-10 coded claims; however, some payers have been selective in terms of the providers with whom they plan to test. This means that some payers may not allow any testing at all. If you’re unable to test, how will you ensure smooth transactions with these entities? Perhaps they will require closer auditing and monitoring – a task for which HIM is well-suited.

Participate in CMS’s testing week with your Medicare Administrative Contractors (MACs) so that CMS can identify and remedy any potential snags in the process. After conclusion of the testing, MACs must report the following information to CMS:

  • Number of trading partners conducting testing during the testing week
  • Percent of trading partners that conducted testing during the testing week (versus number of trading partners supported) by contract
  • Percent of test claims accepted versus rejected
  • Report of any significant issues found during testing

Ask regional HIM peers if they are conducting end-to-end testing, and if so, with which payers. Check payer websites for any information about ICD-10 testing initiatives, and learn more through HIMSS and the National Testing Platform. Any knowledge that HIM professionals can bring to the table in terms of what other providers and entities are doing is helpful.

#2: Select cases for testing. HIM professionals play an important role in selecting the cases that their organization will use for testing purposes. Consider the following tips to optimize any testing opportunities with payers:

  • Don't let payers run the show. Some payers may insist on identifying and testing certain types of cases and claims to be submitted. Look at the data carefully to decide which types of cases should be included. HIM professionals should advocate for a well-rounded testing process that incorporates a variety of records.

  • Collaborate with CDI. Resist the temptation to test only your top 20 diagnoses and then call it a day. The top diagnoses are clearly not the only diagnoses that a hospital reports. Ask CDI professionals to provide input on the diagnoses and procedures that typically lack documentation. Add records with these diagnoses and procedures to your list of cases for testing purposes and submit dual-coded claims. Follow test cases throughout the process to identify if claims are accepted versus rejected and if any documentation is lacking.

  • Look at problem cases in ICD-9. It’s particularly important to test claims that are problematic today in ICD-9-CM. Those claims that are denied today will be denied in ICD-10 regardless of whether your payer or clearinghouse processes them properly. Also test “Not Otherwise Specified” and “Not Elsewhere Classifiable” claims. How do these claims fair, and what steps can you take now to improve documentation?

#3: Ensure data accuracy before testing. It’s simply not productive to perform a thorough and time-consuming test if the data on which the entire test is based isn’t accurate. Claims data must be accurate regardless of when and with whom you test. If the data isn’t accurate, it becomes more difficult to identify the cause of any missteps or inaccuracies in the testing process. For example, if a claim stating ‘pain in limb’ is denied, is it because of an interface problem, or is it because the code didn’t include specificity and laterality?

According to the HIMSS/WEDI National Testing Pilot, which took place April through July 31, 2013, coding inaccuracies abound. The pilot determined that coders often confused the number 0 (zero) with the letter O. They also often confused the number 1 (one) with the letter l (L). Occasionally, coders coded the diagnosis but forgot the procedures. Coders also relied too much on the encoders and reported non-specific codes even when documentation indicated otherwise.

More than 250 healthcare organizations, including providers and payers, participated in the HIMSS/WEDI pilot that ultimately collected more than 200 de-identified standard case scenarios for ICD-10 testing. These cases were hand-coded, vetted by clinical coding experts, and made available to pilot hospitals to use within their end-to-end testing initiatives.

HIM professionals should consider these questions to ensure "clean" testing:

  • Have the correct ICD-10-CM/PCS codes been assigned?

  • Did a coder review these codes for quality assurance prior to sending them?

  • What resources were used when assigning the codes? For example, did the coder use computer-assisted coding? An encoder? GEMs? An ICD-10-CM or PCS manual? All of the above? How did these resources affect coding quality?

#4: Work with IT to configure the test environment so that it mirrors production. According to CMS, “the end-to-end testing process should be performed in an environment which mirrors actual production as closely as possible confirming the validation of performance metrics and analytics.” What does this mean exactly? It means that HIM must ensure that claims used for testing are based on actual clinical scenarios that are clinically coded—not fictitious records that are either payer-generated or that don’t represent a complete, real medical record.

HIM professionals should also familiarize themselves with the National Testing Platform, which uses end-to-end testing method endorsed by HIMSS, WEDI, and CMS that provides participants with valid and clinically-sound cases for testing.

#5: Review, analyze, and report testing results. After you’ve tested, it’s important to review results and take steps to improve processes well before October 1, 2014. Consider the following questions when reviewing test results:

  • Were claims received smoothly, processed correctly, and reimbursed accurately?
  • What percentage of claims were accepted/rejected?
  • What issues were found? Did you receive a report?
  • Was additional documentation needed? If so, what was it? Knowing this in advance can help to offset a spike in Additional Documentation Requests (ADRs) on or directly after go-live.
  • What cases were denied even after ADR fulfillment?
  • Did all interfaces and exchanges between provider/clearinghouse/payer work correctly?
  • What specific cases were denied during testing?
  • How did revenue expectations compare with actual outcomes?
  • How was coder productivity affected? According to the HIMSS/WEDI pilot, coder productivity is expected to decrease by 50 percent, decreasing from four to two medical records per hour.

Get Ready. Get Testing.
Whether your organization is an early adopter of ICD-10 or lagging, end-to-end testing is a critical step to perform during this first quarter of 2014. HIM professionals play a major role in preparing their organizations for ICD-10, and their full participation in end-to-end testing is part of this role.

Wendy Coplan-Gould, RHIA, is founder and president of HRS.