Testing ICD-10 is NOT like Testing 5010: Enabling Tests vs. Logic Tests

Many people talk about leveraging their 5010 test plans and scripts for ICD-10 – and I continue to have a hard time understanding how 5010 brings significant value to the ICD-10 testing challenge. My experience shows that ICD-10 testing will be much more pervasive, complex, clinically-based and, in many cases, may not involve as much vendor/clearinghouse dependency as testing 5010.

See my earlier post on this topic: Leverage Your 5010 Testing for ICD-10 Testing? I think not…

The crux of the difference lies in the number, depth and breadth of clinically-based logic test cases that must be developed.  These “logic tests” will be more difficult to define, execute and evaluate than the “enabling tests” typical of 5010 testing.  By “enabling tests” I mean validating changes made to accommodate the longer ICD-10 code field and to be able to differentiate between I-9 and I-10 codes.  The Y2K remediation was rife with enabling tests.

Simple Data vs. Real-World Data

A key challenge will be bridging the huge gap between the simple ICD-10 test data needed to perform the enabling tests and the more complex, real-world data needed to effect the logic tests. Here are a few thoughts and ideas on logic test areas:

Establishing Clinical Profiles and Episodes of Care

Diagnoses codes are a key element used to assemble patient profiles and determine when episodes of care start and stop for certain conditions like breast cancer, diabetes, hip fracture, congestive heart failure, etc.

DRG, HCC and Other Groupings

Many of these ICD-related data points exchanged between providers, payers and 3^rd parties have yet to be formally updated for ICD-10.  And many organizations are dependent on 3^rd party pricers, code assignment and chart coding services that must be included in test scenarios.

Workflow

Many expensive and/or limited procedures related to sterilization, TMJ, reproductive disorders and fertility, cataract surgery, maternity claims processed under regular hospital benefits, etc. are based on the identification of specific diagnosis code(s) and will require in-depth test case preparation.

Pre-authorization/Referrals & Pre-Existing Conditions

Inaccurate matching, denials and/or delays can have a large impact on financial neutrality and patient service.  Matching claims with either or both I-9 and I-10 codes before and after the implementation date will require a number of detailed test cases.

Wide Variety of Billing and Payment Processes

Physicians, Hospitals, Ambulatory Surgical Centers, Ancillary Providers, Alternative Providers (chiropractors, acupuncture, etc.), Dental and Pharmacy all have unique processes and transactions impacted by ICD-10

For more information on testing ICD-10, see these earlier posts:

ICD-10 Application Integration Testing Considerations & Tips
 
11 Areas to Consider When Testing ICD-10 Impact to Payer Business Processes

Validating and Verifying Your ICD-10 Remediation Efforts

6 Considerations for Verifying ICD-10 Operational Neutrality