Friday, March 30, 2012

ICD-10 Application Integration Testing Considerations & Tips

For many healthcare organizations, testing ICD-10 will be a hugely non-trivial undertaking. Due to the number of interdependencies, integration testing will be particularly cumbersome and requires careful planning to identify the groups of applications that comprise an integration test unit. As applications and business processes are assessed, you need to give a lot of thought and careful planning as to how you will apply and roll out changes to your applications and business processes.
Here are some considerations and tips for testing your ICD-10 applications:
1.      Look at business domains for apps/systems that will see the most impact from the ICD10 changes. The most important systems will likely be those that revolve around your core claims process and enterprise reporting platforms. These systems may serve as the root of your application “grouping” strategy.

2.      Have the folks that are closest to the work involved with test planning to make sure that your technical teams are making the right decisions.

3.      A key factor in determining these groups will be whether 3rd party COTS systems are involved and the vendor’s approach and schedule for ICD-10 compliance.Consider tools and services for clearly documenting and simplifying your testing requirements and processes so they can be performed by the lowest level resources possible and/or outsourced.

4.     Consider building tools and ‘stubs” to enable integration test progress in advance of remediating all components in an integration test group.

Given the current ICD-10 delay scenario, you would do well to use some extra time to consider how you’ll test your applications.  Building in some quality up front is more than just an industry buzzword.

For additional information on ICD-10 testing, see my previous blog posts:

Monday, March 19, 2012

Playing the ICD-10 Who, What, Where Game

Whether you’re a payer or a provider, winning the ICD-10 compliance game necessitates that you rapidly obtain answers to the following questions:

1.       “What” applications and processes include anything related to ICD codes and their use? Ask your workers to briefly describe the workflow and work outcomes for anything that includes an ICD code or an ICD code-based derivative like DRG codes. If possible, have your workers provide the commonly used, internal name used to describe the application or business process. Often times the same work process, application or function within an application is referenced with a different name depending on the person or department.

2.       “Who” are the workers (employees, staff, consultants, business associates, and outside vendors) involved with the ICD-related activity? Describe these “who’s” by their roles as opposed to their name. Outside vendors include trading partners, software vendors, consulting firms, contract workers and others. Identify the name and nature of each outside worker.

3.       “How” is the ICD code used?  Include a description of the application software, business process, reports, forms, workflows, and other descriptive data that would help understand what is impacted. For software and other products, identify the vendor and version of the product(s).

4.       “Where” is the application and/or business process used?  This helps to understand the geographically distribution of workers who perform the activities and to understand potential duplicate and/or conflicting information. 

Because of the far-reaching impact ICD codes have across your business, you should create a simple template for collecting the answers to these four questions.  Request that survey participants attach supporting information such as screen shots, reports, operating procedures and any other information they believe would be helpful.  

The above seems like an obvious and simple game to win and it should be; but you’d be surprised at how many organizations do not have this simple, yet critical information needed to remediate their business and beat the ICD-10 mandate challenge.

Monday, March 5, 2012

11 Areas to Consider When Testing ICD-10 Impact to Payer Business Processes

Remediation of payer systems is not complete without performing adequate testing of revised software applications and business processes. The following are some of the areas that should be considered when creating and defining ICD-10 test plans. 

All Areas
1. Internal and external systems may use an ICD version code so downstream logic can discern code type. This code type must be recognized on an effective dated basis: either date of service or discharge date, depending on setting (inpatient vs. outpatient.)

Logic needs to distinguish version code, date and setting to decide code path.
2. Logic in many areas will be based on configured and cross-walked ICD-10 codes back to a corresponding ICD-9 code(s), or to crosswalk ICD-9 codes forward to the corresponding ICD-10 code(s).

New ICD code crosswalk tables and new cross-walking logic will need to be added at various points throughout the system.
3. Member benefit, provider contract and other configurations will change for ICD-10. Internal and external systems must coordinate their configurations and mapping algorithms to ensure equivalent codes.          

Code configuration and assignment logic must be clearly defined, configured and coordinated between source and target systems.

4. Payers claims entry/correction will use DOS (or discharge date) to determine whether claim ICD version code should be set to ICD-9 or ICD-10 and whether diagnosis codes are interpreted in ICD-9 or ICD-10 format.           
          Modify claims adjudication engine to base diagnosis edits on the claim's ICD Code version throughout.

5. DRG pricing for ICD-9 claims will continue to use ICD-9 format input for grouper. DRG pricing for ICD-10 claims will use ICD-10 format input for grouper.

Logic must be added to DRG pricing so claims will use DRG grouper appropriate for their ICD format.
6. Incoming ICD-10 claims must be matched to ICD-9 history claims. Payers must backward convert ICD-10 codes to ICD-9 equivalent code prior to comparison with history claim.

ICD-10 to ICD-9 reimbursement crosswalk logic will need to be factored into diagnosis related edits that involve historical claim data.
7. Payers cost center assignment logic will use either ICD-9 or ICD-10 codes to determine assignment.

All existing configuration must be enhanced to accommodate ICD-10 codes.
8. Payers will differentiate EOB selection and reporting based on ICD version code and effective date.

All existing configuration must be enhanced to accommodate proper code version and effective date.
Other Areas
9. Prior authorization detail edits will allow only ICD-9 & ICD-10 codes based on dates before or after 10/1/2013.

PA edits will use claim's ICD version code to determine if ICD-10 code on the PA needs to be backward converted to ICD-9 for comparison purposes.
10. Due to expected increase in volume of new ICD-10 codes, manual code update processes will increase significantly.
Automated and manual processes will have to be reviewed with additional time allocated to run times and manual correction activities.
11. Retro third party liability (TPL) mass adjustment claim selection processes must be modified to use either ICD-9 or ICD-10 diagnosis codes for TPL billing determinations based on ICD version code.
All existing configuration must be enhanced to accommodate proper code version and effective date.
Of course this is an incomplete list.  What other new business rules will be impacted by ICD-10?