A majority of the modifications associated with the ICD-10 transition involve changes to internal and external business rules and system workflows. And some software vendors and consultants are touting how their HIPAA 5010 tools and templates can be leveraged to assist healthcare payers with their ICD-10 testing. I just don’t see how transactions used for 5010 testing – whether 4010 or 5010 format - will provide much help with ICD-10 testing.
Perhaps a few scenarios – even those I list below - can be codified into a 278, 837 or other transaction; and maybe some situations during the dual-use period dependent on claim splitting/pivoting around the compliance date can be conveyed via a HIPAA transaction; but there are many business scenarios that were likely not “tested” via 5010 transactions. Most of these scenarios fall within the dual-use period where providers and payers must be able to handle both ICD-9 and ICD-10 codes across the Oct 2013 transition date and for a period thereafter. And others have to do with the type of ICD code contained on the transaction.
Here are some scenarios that I think transactions used for 5010 testing will do little, if anything, to assist with:
1. Ensuring external causes are properly identified for assigning other party liability (OPL). These “E” codes were easy to identify in ICD-9.
2. Body part assignment logic associated with OPL investigations
3. Date sensitive access to and application of business rules related to clinical editing, claims adjudication, fraud detection, and care management are appropriate and align with business objectives. (dual-processing)
4. Linking or aggregating claims received prior to 10/1/13 coded with ICD-9 codes to claims received after the 10/1/13 compliance date coded with ICD-10 codes.
Here are some scenarios where I think 5010 transactions could be leveraged:
1. Identifying and rejecting claims containing services that span the transition date.
2. Accessing appropriate member benefit and provider contract terms based on dates of service or discharge date – depending on claim type.
The above is just a short list but my thought remains that defining test strategies, developing test plans, developing test data, and developing test scenarios to address ICD-10 will not be made “easier’ by work expended on 5010 testing. Are these vendors and consultants suggesting that they CAN create 5010 transactions to address the scenarios I describe? Or are they suggesting they already exist from pervious 5010 testing effort? I think not. But maybe I’m wrong? If so, someone please clue me in.