Thursday, November 29, 2012

ICD-10 Medical Testing Scenarios – Be Happy in the Morning – Not Mourning

If anyone thinks they will be able to perform comprehensive testing of all ICD-10 coding and processing scenarios, they’re on a Fool’s Errand. There are just too many potential claim coding and payment processing variations between providers and payers due to how selected ICD-10 codes can be applied to benefit plan and medical management policies.  Add in the unlikely readiness and unpredictability of multiple vendor systems and intermediary processing through claim pathways and you’re on your way to going out of business.

Here are some information, ideas, opinions and random thoughts about using medical scenarios to focus your ICD-10 testing.
What’s Your Scenario? Do You Come Here Often?

Spend some time identifying your most common medical scenarios by determining high volume, high-risk ICD-9 codes. Then look at how the following may alter each of these medical scenarios:

1. Type of encounter (initial or subsequent or sequelae?)

2. Applied specificity (did the patient lose consciousness?)

3. Acute versus chronic

4. Relief or non-relief (intractable versus non-intractable?)

5. External cause (was it caused by an accident? – i.e. Other Party Liability?)

6. Activity (what was the patient doing when ‘injured?’)

7. Location (where was the patient when injured?)

Define standard test data sets for each of these medical scenario variations. Determine which ICD-10 code(s) YOU THINK are associated with each of them. Then get your payer/partner to what THEY THINK and have them explain how they’d process your scenario AND their scenario.
If your existing medical records don’t have enough detail to create these medical scenarios, then make up the data. And start planning how you’re going to improve your medical records!

Healthcare is Local
Consider how your locale, region and state may dictate the composition of your medical scenarios. Certain medical scenarios may apply only to a specific region, locale or state.

“Edge” providers and payers servicing two or more states may have extra work to do.
Focus, Focus, Focus – Choose Wisely

You MUST manage the scope of your medical scenarios –or you’ll end up defining many poorly defined scenarios instead of fewer, more important scenarios that thoroughly reflect your business.
Avoid wasting time on customized variations and edits associated with certain trading partners – unless they represent a major portion of your business

Testing with external partners requires multiple companies to be “ready” and have resources committed to test at the same time.
If ever there was a time to focus on the Pareto Principle it’s with ICD-10 testing.

Either You’re With Us or Against Us
Payers and providers will be impacted by, but may have limited control over, vendor readiness, including their test schedules and ICD-10 remediation logic. 

Make a concerted effort to reach out to your primary business partners and document your interactions with them.  Sometimes you’ll have no control and be ignored. Don’t sit back.  Approach and confront, if necessary
<Lawyering On> Having clear, contemporaneous records of your interactions with business partners is ALWAYS a good thing. <Lawyering Off>

The Scenarios Better Work Good in the Morning
The ICD-10 morning is coming October 1, 2014. No one wants to wake up mourning over a nightmare.  So think about some of what I’ve presented above and make a pledge to make smart choices as to which ICD-10 Medical Scenarios you choose at closing time approaches.

If you want to learn more about ICD-10 and Healthcare IT in general, be sure to Follow me on Twitter.

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