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ICD-10 Testing – Data Integrity and Coding Accuracy

February 4, 2014

ICD10 CrossoverThe much anticipated and somewhat dreaded transition from the ICD-9 to the ICD-10 medical codes is required by October 1, 2015. It’s already been delayed once, from October of 2013. HHS officials in a summary of the final rule reasoned that it was to give “covered health care providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition.” HHS anticipated that providers’ lack of readiness for a 2013 compliance transition would cost between 3.8 and 10 billion dollars in erroneous billing coding, hence the delay to 2015. There are no indications that implementation will be delayed any further.

ICD-9 to ICD-10 is of course a major sea change for providers: The approximately 13,000 ICD-9 codes are over 30 years old and lack the specificity that the longer ICD-10 codes lend to diagnostic definition, patient treatment and billing. To achieve this improvement, the number of diagnosis codes will increase from about 14,000 to 68,000, with procedure codes increasing from about 4,000 to 87,000. Adding to the transition challenge for medical practices and billing services are the differing lengths and structures of the two code sets. The 3 to 5 digit ICD-9 codes are almost entirely numeric, with only a leading alpha character, while the ICD-10 codes are 3 to 7 characters. The last four characters of the ICD-10 codes can be either alpha or numeric. It’s the length and flexibility of the ICD-10 codes that make them suitable for defining contemporary medical health records while at the same time making conversion extremely challenging.

Multidimensional Transition

The ICD-9 to ICD-10 transition is more than a technically complex data conversion exercise. Successful conversion and testing have to be preceded by assessment and remediation selections, and take into consideration the business drivers of the environment, not just the technical requirements of conversion. These embrace clinical equivalency, benefit neutrality, financial integrity and operational stability.

ICD-10 Conversion Outcomes

·        Clinical equivalency: Use of either the ICD-9 code or its equivalent ICD-10 code define the same attributes of patient care, medical necessity and treatment outcomes.

·        Benefit neutrality: Use of either the ICD-9 code or its equivalent ICD-10 code produce the same member coverage, without increasing member premium or out-of-pocket expense.

·        Financial integrity: Either set of codes results in the payment of appropriate benefits by the insurer and the appropriate financial contribution by the recipient.

·        Operational stability: Accuracy metrics such as auto-adjudication frequency and claims payments are at equivalent acceptable levels under either the old or new codes.

ICD-10 Conversion Process

A successful ICD-10 conversion requires the sort of careful planning recommended by CMS. It falls into the areas of Assessment, Remediation, Testing, Implementation and ICD-10 Based Processing:

Assessment: Determine the impact conversion to ICD-10 will have on people, processes, partners and systems. What will be the impact of ICD-10 based rules on associated automated processes and payments?

Remediation: How can you best change your current automated systems to achieve ICD-10 implementation? This is very much a cost-benefit analysis. The most complete option is to replace your systems to make them fully ICD-9 and ICD-10 compliant. A system with this dual-utilization capability will require less manual intervention while allowing full utilization of the enhanced ICD-10 data. This can be very expensive.

The other option is the crosswalk option, wherein ICD-9 codes map to ICD-10 data through a conversion process implemented in your current system. It’s a short term solution and one prone to problems: all systems must be ICD-10 compliant by 2015, eliminating data cross walking as an option. Also, ICD-10 crosswalk data often fails downstream to provide critical information to medical management pricing and contract applications.

Testing: With remediation determined, a test plan needs to be written that includes both technical and functional requirements. System performance testing and tuning need to occur, along with a determination of the conversion’s effects on such outcomes as provider management, customer service and patient billing. The test environment, test data, strategy, and scenarios should be built with your business partners around the goal of maintaining operations as usual during and after ICD-10 implementation.

ICD-10 Based Processing: With your conversion strategy validated through robust test instances over a variety of scenarios, you’re ready for October 2015 and ICD-10 implementation. As with all conversions, there will be bumps in the road, but careful planning, testing and implementation will ensure ultimate success.

Where should you be in the transition process?

 According to the American Health Information Management Association (AHIMA) you should have begun training at the start of 2014. A minimum of 16 hours of training with diagnostic codes is deemed essential. Providers who have just begun transition are urged to create a transition team, develop a transition plan, analyze the effects on your organization, consider how EHR templates will affect your clinical documentation, secure a budget and begin to work on transition along with payers, billing and IT staff, and practice management system and/or EHR vendors. Remember the October 2015 deadline is unyielding.

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