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.
Claims

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?


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