CODING corner While the transport aspects of the icd-10 cm processing have, for the most part, been achieved, many – if not all – electronic data interchange/clearinghouse vendors will need adequate time to incorporate updates to their data validation or edit systems. this includes code validation, date validation, medical necessity validation, correct coding initiatives, and all published and promulgated payor rules based on diagnosis and procedure coding. one of the lessons learned during the 5010 conversion was that adequate notification of the coding edits will be necessary to ensure successful testing between feeder systems (Pms and his) and the electronic data interchange/clearinghouse systems, as well as any contemplated testing between payors and providers. We know cms heard this message and has established a work group of collaborating industry partners tasked with the establishment of benchmarks that cannot be ignored to assess the status of “ready” and “end-to-end” testing for the healthcare industry. finally, it is likely that some payor systems will not be able to process true icd-10 cm codes at the point at which the icd-10 cm goes into effect. some payors have acknowledged that they will convert icd-10 cm into icd-9 cm with crosswalks for adjudication purposes, and that some type of conversion will take place when providing electronic remittance transactions back to the providers. this will result in providers needing information to determine if payments are in accordance with contracted agreements between providers and payors. the journal of the healthcare billing and management association 41 hbma has proposed two key recommendations: 1. CMS should adopt and enforce a uniform definition of "ICD-10 CM ready.” as you know, some vendors and health plans have already announced that they are icd-10 cm ready. clearly, this cannot be true as there has been no external end-to-end testing or payment impact analysis for claims other than the cms-3m project for drg to icd-10 cm comparison. because there is currently no definition of “ready,” plans and vendors can make their assertions without consequence. “icd-10 cm ready” should mean, at a minimum, that the complete end-to-end testing of 837 and 835 transactions in full production has successfully been accomplished. maps or crosswalks used by a health plan to adjudicate a 5010/icd- 10 cm compliant claim must be publicly available and the diagnosis code(s) used for claims adjudication reported. hbma recommends that health plan coverage policies be published by october 1, 2013. this would allow adequate time for education and training, programming, data analysis, and incorporation into end-to-end testing. hbma also recommends that the definition of “ready” include all of the transaction types, not just the ability to submit claims or process remittances containing icd-10 cm codes. 2. HBMA recommends that CMS identify and publish specific, verified readiness milestones for providers and insurers. in addition, as we have recommended in the past, hbma strongly recommends that implementation milestones be tiered as follows: a. one milestone date for all systems to complete data interchanges between systems other than payors b. one milestone date for completion of testing with all payors c. one milestone date for production with all payors a full year of true end-to-end testing should be provided with clear dates for when payors must have a testing schedule established. in addition, the testing should provide for a full week’s worth of de-identified production claims processed in a test harness. this will account for all possible test scenarios. failure to require all payors, providers, and vendors to adhere to established timelines, testing schedules, complete and thorough end-to-end testing, transparency in transactions, and definitions could result in insurmountable problems. because icd-10 cm is the foundation for multiple other cms initiatives, successful transition and implementation of icd-10 cm has broad implications. coordinated industry collaboration and cooperation is necessary for success. the definitions of “ready” and “endto end” testing must be agreed upon, relied upon, and used as the criteria for objective evaluation of the ability to successfully transition and implement icd-10 cm. Holly Louie, RN, CHBME, PCS, is the compliance officer for Practice Management, a multi-specialty billing company. She is a member of the HBMA Board of Directors and she chairs the ICD-10 Committee. The committee is comprised of HBMA members and vendors.
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