Between providers and payers, it appears that everyone is ready for end-to-end testing of ICD-10 transactions. But where is health information management (HIM)? A quick tour of the American Health Information Management Association’s (AHIMA’s) ICD-10 website reveals little mention of this massive undertaking. And most of the HIM professionals we meet are barely aware of the national pilot program for ICD-10 testing. Why is this?
Perhaps it is because HIM professionals were a step removed from the ANSI 4010A1-to-ANSI x12 5010A1 transition. Three organizations, however – the Healthcare Information and Management Systems Society (HIMSS), the Workgroup for Electronic Data Interchange (WEDI), and the Centers for Medicare & Medicaid Services (CMS) – were keenly aware of the 5010 disaster and are committed to not repeating the same mistakes. They are working collaboratively to develop test scenarios, best practices and free resources for providers, payers, clearinghouses and health plans. The HIMSS/WEDI and CMS ICD-10 trains have left the station. It’s about time HIM professionals jump aboard!
The implementation of 5010 proved one thing: changes to healthcare’s payment model cause massive disruption. And compared to ICD-10, the move to 5010 was a walk in the park. The ICD-10 transition represents a tenfold leap in complexity, duration and cost. To avoid the same mistakes that led to 5010 delays and denials, ICD-10-coded transactions must be tested thoroughly across the entire healthcare spectrum (hence, end-to-end testing), with all types of real-world clinical scenarios being considered.
All stakeholders must take small, incremental steps, with all changes to be completed by October 2014. Relying on mapping tools and scenario syntax alone simply won’t work. Repeated testing with real-world, hand-coded cases is the only proven way to find problems ahead of time and subsequently determine what to fix, making dual coding a precursor to end-to-end testing.
To help organizations prepare, HIMSS, WEDI and CMS each have launched pilot programs. All three were discussed at the recent HIMSS ICD-10 Symposium. An entire afternoon was dedicated to end-to-end testing models, progress and advice, and here’s what they said.
The HIMSS/WEDI ICD-10 National Pilot Program is the only multi-stakeholder program of its kind designed for testing ICD-10 claims across enterprises. HIMSS and WEDI are working collaboratively with more than 200 healthcare organizations to build test scenarios using real cases and all available clinical documentation. Cases are vetted fully by an array of program participants and coded by AHIMA-certified ICD-10 coders.
The pilot program is based on the Lott Method, the only proven approach to asynchronous end-to-end testing. The Lott Method uses manually coded, clinically based test cases instead of fictitious files. De-identified, complete medical records are the foundation for this method.
In the HIMSS/WEDI pilot, test cases are shared by vendors, hospitals, providers, clearinghouses, payers and other entities. The same set of medical records and data is used to review, code and compare cases. A central hub maintains communications and shares results between parties.
HIMSS and WEDI will be conducting pilot tests with their initial scenarios between now and July 2013. This testing phase will be extended during the second half of 2013, with full industry testing of standard scenarios occurring in 2014. Providers should see the first set of free, online scenarios becoming available this summer. And HIM professionals, take note: any provider able to submit its manually coded ICD-10 cases is welcome to participate. For more information about the HIMSS/WEDI pilot, go online to http://www.himss.org/library/icd-10/national-pilot-program?navItemNumber=13477.
CMS also offers testing resources and support, but of a totally different flavor. The CMS initiative is a universal testing process using methodology of all regulatory changes from the healthcare simplification set. While their tool sets and resources can be used for ICD-10 implementation, they are also valuable for navigating other changes. CMS is not developing software, testing data, or a testing environment. Output from their efforts will be available to everyone and shared nationwide.
Eighteen industry collaboration partners are involved in the CMS program. HIM professionals are encouraged to participate in weekly listening sessions and submit questions via email. The program is currently in its second phase, with the third slated to run from July through September. For more information about CMS resources, go online to http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10/.
From the HRS perspective, a lot was learned during dual coding and initial phases of end-to-end testing. First and foremost, dual coding should not be labeled a coding audit, but simply a feedback mechanism used for finding weaknesses in documentation and coder education.
Dual coding for end-to-end testing uncovers all the various gray areas within the ICD-10 coding guidelines. In our experience, preliminary findings in particular highlight those gray areas, especially in procedure coding. Clinical nomenclatures change dramatically in ICD-10 procedure coding, and these changes don’t match up well with physician-speak. As such, differences in how coders interpret ICD-10 coding guidelines abound.
For those organizations currently dual coding for end-to-end testing, a best practice is to use the full footprint of an encounter (complete medical records) and provide reviewers with access to the same. Whether ICD-10 coders are internal or external, they must review entire sets of actual source documents. Just like in ICD-9, codes only can be assigned based on the available clinical documentation, and again, entire record sets are necessary to validate the codes sent.
The most important goal connected to your ICD-10 efforts should be to find problems now rather than later. Preliminary assessments, dual coding, education and ongoing documentation improvement together should achieve this goal. There is no time to wait for technology vendors or system interfaces. Organizations must begin now, in early 2013, even if manual efforts are required.
The participation of HIM professionals in end-to-end testing is critical, primarily to produce ICD-10-coded cases using existing documentation and real-world medical records. Once coded, conversations and testing with third-party payers and clearinghouses can begin. Now is the time for HIM professionals to get involved. And joining one of these two initiatives is the place!
About the Author
Elizabeth Stewart, RHIA, CCS, CRCA, is the corporate director of HIM for HRS. Her areas of expertise include coding, HIM, patient access and patient financial services, plus compliance and HIPAA privacy and security. In addition to her role at HRS, she continues to serve as the executive director of the South Carolina Health Information Management Association.
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