ICD-10: What is End-to-End Testing? By Holly Louie, RN, CHBME, PCS and the HBMA ICD-10 Committee he gravity of undertaking a complete replacement of one of the most essential elements of the healthcare reimbursement mechanism cannot be overstated: if the ICD-10 CM implementation is executed flawlessly, there will be little difference between “before” and “after;” if there are problems, the impact will range from painful to cataclysmic. changing the way we code, process, and adjudicate medical claims is effectively altering the payment model, which could play havoc with the healthcare industry at large. We must learn from the mistakes that were made in transitioning from 4010 to 5010 and undertake the transition from icd-9 cm to icd- 10 cm in a way that demonstrates we learned those lessons. in our view, central among the shortcomings in the 5010 transition was the lack of a standard definition of what it meant to be “5010 ready.” What we subsequently learned was that every entity in the claims processing chain had a different definition of what they meant by the term “ready.” We believe it is not possible to be “ready” until meaningful, end-to-end testing has been successfully accomplished. We have also learned from the 5010 conversion that payor testing was severely limited. the first six months of 2012 underscored this point: many payors only tested syntax prior to the implementation of 5010, and in many cases the scope of testing did not adequately cover the true edits. additionally, their preparation did not provide for end-to-end testing with full claim-level adjudication and remittances as part of the test. as we all know, icd-10 cm will have far more impact and significantly greater change than 5010. unlike 5010, physicians must be personally and actively involved in the icd- 10 cm process. We are concerned that unless the “lessons learned” from 5010 materially inform and affect the implementation of icd-10 cm, the economic stability of america’s healthcare reimbursement systems will be at risk and could be severely compromised. We cannot stress enough that in relative terms, adoption and implementation of 5010 was simple compared to the much greater magnitude of icd-10 cm. every vendor system that stores, uses, depends on, transmits, or receives an icd code, for whatever purpose, must modify some component of their practice management (Pm) software to accommodate icd-10 cm. in the process, each vendor is forced to make decisions and set rules or policies regarding how they will treat icd-10 cm codes and handle the transition from icd-9 cm to icd-10 cm. While some elements of the modifications necessary to prepare for icd-10 cm have been addressed by many vendors, payors, and clearinghouses during the transition from ansi 4010a1 to ansi X12 5010a1, an enormous amount of work remains to be done. if data cannot get to its intended location in the proper form and be received and interpreted in that established form, then submission of claims – certainly “clean” claims – that would result in appropriate payment can be interrupted. innumerable interfaces exist because there are various approaches that the “owners” of each type of system can take when setting policies for handling data interchanges that involve icd codes. some owners may choose to use the general equivalence mappings (gems), proprietary translation tools, or other methodologies. others may choose to extend maintenance and support of both icd-9 cm and icd-9 cm tables well beyond the final implementation date for icd-10 cm. in fact, hiPaa-exempt insurers such as automobile, tort, and workers compensation plans may continue to utilize icd-9 cm for years to come. because there are at least two entities involved in each interface, there must be ample time allowed for communication and the necessary development/modifications between every data trading instance to handle the specifics of each interface. the process of building these communications and translations between the interfaces will be very time and resource consuming, and failure to establish them properly could create chaos in the healthcare world. Providers and billers could be rendered incapable of functioning if these are not considered along with sufficient time provided for their development by october 1, 2014. T 40 hbma billing • may. june.2013
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