Thomas Edison. Nickolas Tesla. Two hundred years ago, Edison and Tesla proposed different approaches to solve the same, unified problem — how to illuminate the world. Today, we face a similar quandary. How do we most efficiently test billing transactions and ensure a clean transition from ICD-9 to ICD-10?
Certainly, the methods we used in 2012 to transition from the HIPAA electronic claims standard version 4010 to version 5010 were not successful. Timelines got pushed back and reimbursements were delayed.
With ICD-10, new testing environments are needed and new approaches must be applied. The healthcare industry proposes two approaches: The first uses real-world, standard case scenarios coded in ICD-10, while the second applies General Equivalency Mappings to existing ICD-9 claims. This article briefs healthcare executives on the pros and cons of both methodologies.
Testing with real-world case scenarios
The HIMSS/WEDI National Testing Pilot was active from April through July 31, 2013. Over 250 healthcare organizations, including providers and payers, participated The HIMSS/WEDI pilot collected over 200 de-identified standard case scenarios for ICD-10 testing. These cases were hand-coded, vetted by clinical coding experts and are now available for hospitals to use within their end-to-end testing initiatives. Subsequently, an ICD-10 National Testing Program was launched by the industry consultancy, the Lott QA Group. Cases donated for the HIMSS/WEDI pilot will also be used for the NTP.
While the HIMSS/WEDI National Testing Pilot and the NTP represent two separate projects, they are based on the same methodology: Use real-world, hand-coded cases as the optimal foundational for asynchronous, end-to-end testing among healthcare’s ICD-10 trading partners.
Hand-coded, de-identified cases are used instead of fictitiously mocked-up files or ICD-9 to ICD-10 data mapping. HRS was one of the first coding companies to support these efforts. The same set of medical records and data is then used to review, code and compare. The program delivers high-value collaboration across all ICD-10 trading partners with test cases shared by vendors, hospitals, providers, clearing houses and payers. Rather than burden each organization's staff with testing, a central hub maintains communications and shares results between parties upstream and downstream in the revenue cycle.
Payers review codes and documentation before replying back to providers through the central hub. Then they return coding and adjudication outcomes to the provider. Payers also apply lessons learned to adjust their own internal mapping and claim logic when discrepancies are discovered. All participating organizations share knowledge and lessons learned along the way. Other advantages of asynchronous, end-to-end testing using real-world scenarios include:
• Reflects your true ICD-10 financial and operational impact, based on your unique set of clinical documentation and coder skill set.
• Uncovers gaps in clinical documentation and coder knowledge to fine-tune your educational efforts.
• Reduces your cost of ICD-10 end-to-end testing through shared test cases and a central communication hub.
General Equivalence Mappings
Another ICD-10 testing methodology is the use of GEMS. Many healthcare payers state that they will use GEMS for their baseline mapping system and ICD-10 testing. Providers are also using GEMS to estimate their general financial impact. GEMS information is available via the CMS website, which is free to all healthcare stakeholders.
The problem with GEMS is that more than 20 percent of Medicare codes in ICD-9 do not map to codes in ICD-10-CM/PCS. Furthermore, GEMS can be disabled and maps can be added to "fit" each payer's unique rules. WellPoint is one payer currently using GEMS for ICD-10 mapping and testing. For example, a recent article in the Journal of AHIMA states that "the Code Set Competency Center at WellPoint maintains a list of all codes that require the payer to disable the GEM."1
Discuss mapping methodologies with your payers now. Connect with regional peers and join collaboratives to fully understand each payer's unique ICD-10 testing plans.
GEMS are readily available for testing and have set general ICD-10 expectations, but they won't paint a true picture of your specific ICD-10 financial and operational impact. Also, your unique clinical documentation and coder skill sets cannot be assessed through this testing methodology.
Mitigate ICD-10 risk now
The financial ramifications of poorly executed ICD-10 conversions could be devastating, especially for smaller hospitals and physician groups. Even well-planned implementations can face revenue losses due to denied claims, failed medical necessity or insufficient coding staff.
End-to-end testing between providers, payers and clearinghouses, when it is conducted early and often, identifies potential weaknesses well in advance of Oct. 1, 2014. And it ensures that all parties have the opportunity to shore up their people, processes and technology to keep claims and reimbursement flowing.
Rather than waiting to test claims just prior to the Oct. 1, 2014 deadline, collaborate with vendors, clearinghouses and payers now, in 2013. Convert claims to paper if necessary. Test only a few claims processing steps. Both of these scenarios are acceptable, as long as some type of testing begins. Do whatever you can now, and expand outward from there.
In the future, we may still debate the use of GEMS versus the real-world case scenarios for ICD-10 testing, just as our forefathers pitched Edison against Tesla. But regardless of the methodology you use, your ICD-10 lights will come on!
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, 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.
Wendy Coplan-Gould, RHIA, has led HRS, a health information management consulting and outsourcing company, since she founded it in 1979. Coplan-Gould provides strategic leadership and business development for HRS, applying her expertise in the areas of operations, clinical documentation and coding. She has been published in multiple journals and has conducted countless professional presentations.
1 The Final Countdown. Industry Moves Closer to ICD-10-CM/PCS Implementation Deadline. Eramo, Lisa. Journal of AHIMA. June 2013.