Identifying and Categorizing ICD-10 Test Cases - 6 Key Elements

Developing the test cases to verify and validate your ICD-10 remediation efforts is no trivial task. Where do you start? What are the key elements needed? How can you leverage certain tests across different areas? How do you know when you have covered all the bases? It’s easy to get bogged down and overwhelmed by the shear depth and breadth of testing requirements.

As someone smart once said “The journey of 1000 miles begins with a single step.” The purpose of this post is to provide you with information on creating a map to guide you in making that first step toward developing your ICD-10 test cases.

Six Key Elements

Type of Test - Describes the general area addressed by the test case. Examples include:

Pre-authorization required
Claim Processing – DRG pricing
HCC Risk Assignment
Actuarial Analysis – High Cost Conditions
Pre-existing condition
Other Party Liability Claim

Product or Line of Business- Identifies the specific product or line of business to which the test is targeted. Examples include:

Commercial
Medicare
Medicaid
Dental
HSA

Type of Transaction - Defines the type of transaction involved with the test case? Examples include:

Institutional Claim
Professional Claim
Dental Claim
Pre-authorization
Claim Status Inquiry

Key Test Variables - Lists key data elements/variables involved with the test.  Examples include:

Procedure Code
Revenue Code
Diagnosis Code
Provider Category
Provider Type/Specialty
Date of Service
Date of Discharge
Place of Service
Bill Type

Exception Conditions- What are the exceptions that should be anticipated for the specific test case? Examples include:

Accumulator Maximum Reached
Pre-existing condition detected
Claim denied due to benefits
No pre-authorization on file
Claim out sorted in workflow

Verification & Validation Areas- What data elements, variables and outcomes are associated with a successful test? Examples include:

Limits
Deductible
Coinsurance
Copay
Claim Status

By creating a grid with 6 columns and collecting the above information for each test, you’ll have assembled the important, high-level information you'll need to triage and flesh out the details of your test cases - before diving into the details of individual tests.