The Centers for Medicare & Medicaid Services(CMS) has gained breakthroughs by a successful session of ICD-10 end-to-end testing. However, what does it actually signify for medical professionals? It has great importance for healthcare providers. They become able to identify health conditions with greater specificity and measure the quality of patient care efficiently.
Although, testing is critical to understand as problems often arise after the implementation. As a result, you can experience rejections which can severely influence the revenue stream of your healthcare practice. The fewer denials you will have to rectify the more you resolve and discover ICD-10 glitches on time.
The impact will range to painful from cataclysmic, if there will be little difference between “before” or “after,” the implementation of ICD-10-CM. Changing the payment model will not only impact the reimbursement mechanism but also lead to greater disruption to healthcare practice.
It is tantamount to changing the payment model entirely if you change the way to adjudication of medical claims, processing medical claims, and coding the claims accurately. The best way to efficiently handle this situation is to undertake the transition to ICD-10-CM from ICD-9-CM in a way that will signify the learning.
According to a report, the standard definition of what it implies to be ‘’5010-ready’’ was the lack of centrality among the shortcomings in the 5010 transition. Yet it had a different definition of the term ‘ready’ for every entity in the claim processing chain. Until meaningful end-to-end testing is not done it is not possible to be truly ‘ready’.
Payer testing has been severely limited from the 5010 conversions. ‘’Many payers only tested syntax prior to the implementation of 5010’’, it was underscored during the first 6 months of this year. In several cases, these efforts did not involve end-to-end testing with remittances, and full claim level adjudication plus the extent of testing did not recount actual edits adequately.
It is understood that ICD-10 holds more influence than the 5010. Healthcare providers must be actively and personally involved in the process of ICD-10 unlike the 5010. Healthcare organizations could not compromise as the financial stability of the US healthcare reimbursement systems will be at risk, unless the lessons learned from 5010 affect the implementation of ICD-10 CM. They must not stress over the implementation and adoption of 5010, in relative terms, it was simple compared to ICD-10 CM.
Why Is End-to-End Testing Necessary?
Testing is necessary for ensuring the uninterrupted flow of transactions with trading partners and assuring compliance with the requirements adopted by the Secretary. Covered entities will need to implement a process to aid the industry in performing end-to-end testing and meet the compliance dates remarkably.
The process of end-to-end testing involves the healthcare provider’s receipt of a (RA) Remittance Advice and submission of test claims with ICD-10 codes to CMS. Patients will have RAs provided by Medicare to justify denials or adjustments and explain reasons for payments. The basic objective of this end-to-end testing is to demonstrate;
- Claims processing results in accurate remittance advice.
- Support ICD-10 results in properly adjudicated claims by making modifications in CMS software.
- Healthcare providers can successfully submit ICD-10 claims.
3 Steps to Take
Address Potential Problems
With testing, healthcare providers will be able to know how readily payers will deny those claims that will not meet their expectations and figure out what level of specificity payers are expected to see. For instance, with one comparable ICD-9 code several latest ICD-10 codes correlate.
Even though these codes might not influence the amount to be paid. There are more specific codes that are vital for the approval of certain payments. To ensure a successful ICD-10 implementation and jumpstart your testing initiatives, it is highly crucial to put the right assets in the right place.
Identify Key Trading Partners
- Billing services.
- Systems providers.
It would have the biggest impact on your healthcare organization if denials were to happen. So, it is the best strategy to start with your largest payer first. Afterward, simply just go down the entire list. Determine if trading partners will be ready to accept test transactions and ask what information they require to initiate the testing procedure.
Create a Timeline
For reducing the denials and improving the process, create timelines so your testing can be done as soon as possible.
How to Accommodate ICD-10CM?
To accommodate ICD-10 CM, every vendor must have some degree of modification that should be made to the software’s components that store, utilize, receive or transmit the ICD code for whatever purpose. So, in the entire procedure, every vendor must know how to handle the transition to the new coding set. They must have set policies or rules and techniques regarding how it will work with ICD-10 CM codes.
An enormous amount of work remains during the transition to ANSI X12 5010A1 from ANSI 4010A1. While many payers, vendors, and clearinghouses address some elements of the modifications necessary to prepare for ICD-10 CM. The submission of claims can be interrupted if the data is interpreted in the proper form and cannot get to the intended location in the proper form.
When setting laws for managing data interchanges involving ICD codes there are many approaches that each system owner can take. Various owners may decide to utilize different methodologies, proprietary translation tools, and GEMs mapping systems. While others may support both ICD-9-CM tables and ICD-9-CM and extend maintenance beyond the final date of ICD-10 CM implementation.
For every data trading instance to handle the specifics there must be ample time allowed for necessary modification/development and communication because there are two entities at least that are involved in each interface. This will be a very resource- as well as time-consuming activity to build these translation systems along with communication. It will create chaos in the healthcare world if you fail to execute them properly. When the time frame for ICD-10 CM is finalized medical billers and providers must be capable of functioning if systems are not developed in a sufficient time.
Vendors will require enough time to consolidate updates to their edit or data validation systems while the transmit aspect of ICD-10 CM processing for the most part has been covered. It involves;
- Date validation.
- Code validation.
- Correct coding initiatives.
- Procedure coding.
- Medical necessity validation.
- Promulgated & published payer rules based on the diagnosis.
For ensuring successful testing between payers & providers, feeder systems (HIS or PMS), and the clearinghouse systems/electronic data interchange for adequate notification of coding edits is highly necessary. CMS has assigned the following tasks to the workgroup of the industry partners;
- Assess the status of “ready” & “end‐to‐end” testing.
- Establish benchmarks that cannot be ignored.
At the point where ICD-10 CM goes into effect, payers will not likely be able to process true ICD-10 CM codes. With crosswalks for adjudication purposes, some payers have acknowledged that they will convert into ICD-9 CM from ICD-10 CM. In addition to this, when providing electronic remittance transactions back to the providers that some type of conversion will take place. Eventually, payments will be in accordance with the provider & payers’ contracted agreements while the providers will determine them after taking the required information.
Healthcare providers submit claims with accurate ICD-10 codes during testing. To return electronic remittance advice (ERA), the claims are processed through system edits by health plans. If your testing is not yet conducted, you must discover opportunities to check with your outsourced billing services, health plans, and clearinghouses.
A uniform definition of being ‘’ICD-10-CM-ready’’ must be adopted and enforced by the CMS. However, some health plans and vendors have already declared themselves as ‘’ICD-10-CM-ready’’. But, clearly, it is not true, there is no payment impact analysis or external end-to-end testing for claims performed. Vendors and health plans can make assertions without consequence as there is currently no true definition of “ready’’.
“ICD-10-CM-ready” signifies the achievement of complete end-to-end testing of ( 835 and 837 ) transactions in full production. The diagnosis codes used for claims adjudication must be reported or 5010/ICD-10-CM-compliant claims adjudicated by health plans should be made publicly available.
Healthcare Billing and Management Association (HBMA) encourages the submission of health plan coverage policies as soon as possible. It will provide sufficient time for training, education, programming, incorporation into end-to-end testing, and data analysis. Besides, HBMA also proposes the description of ‘’ready’’ comprise of tasks such as;
- Process remittances containing ICD-10-CM codes.
- Involve all the transaction types.
- Claim submission.
Healthcare Billing and Management Association encourages that the Centers for Medicare & Medicaid Services verifies readiness milestones for insurers & healthcare providers by figuring out and publishing specifically. It strongly recommends that implementation milestones be tiered as below;
- Date for production with all payers.
- Date for ending of testing with all insurance carriers.
- Date for data interchanges between systems used by entities instead of payers.
It should be mentioned when payers must have a testing schedule established with clear date sets a full year of true end-to-end testing should be available. All possible test scenarios will be taken into account if in a test harness the testing should ensure a whole week of de-identified production claims processing.
It could result in insurmountable problems if all vendors, payers, providers fail to adhere to;
- Testing schedules.
- Established timelines.
- Transparency in transactions.
- Complete and thorough end-to-end testing.
Because ICD-10 CM has broad implications as it is the base for implementation of ICD-10-CM, successful transition, and multiple other CMS initiatives.
End-to-End Testing Value
With multiple payers testing provides value as it:
- Shows how significant end-to-end testing is for ICD-10.
- Verifies trade partner ICD-10 readiness.
- Builds rapport among trading partners.
Overall, it may be said that the necessary components for success are coordinated industry cooperation and collaboration. The ability to implement ICD-10 successfully for objective evaluation relies on the definition of ‘’end-to-end testing’’ and ‘’ready’’.
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