Preparing for ICD-10: Implementation and Testing

Preparing for ICD-10: Implementation and Testing

Change, change, change, change, change, etc. ICD-10 requires a lot of it Everywhere IT systems Business processes People By everyone Practices Payers Vendors 2

Aspects of Change Every change requires: Money Testing Training Installation into production Monitoring Levels of each will vary depending on the combinations of: Vendor Extent of update or replacement Dependence of the change on other items or things Dependence of change on systems, policies or people outside of your practice. 3

Diagnosis codes they re used a lot Before discussing implementation and testing, to understand the scope, remember that diagnosis codes: Establish payment Contracting Part of auditing Case management Quality measurement and reporting Assess utilization measurement, patterns Population risk assessment Clinical research and trials Patient safety review/policy development 4

Diagnosis codes they re used a lot! In many practice s systems: Patient registration Clinical documentation / health records Referrals and authorizations Coding Lab, test and other physician orders Billing Reporting and analysis Payer contracting and medical policy requirements Public health reporting Compliance management 5

System Dynamics Systems are composed of individual elements working for a common goal Parts or elements depend on each other They may be: Electronic or manual or paper Completely internal Completely external Self-developed within your organization Frequently some or all of a system s components are purchased from external vendors Many systems are likely combinations 6

Internally Created Components Your organization is responsible for making any necessary adjustments to accommodate ICD-10 Keep in mind that electronic system updates require significant extras Software requirements documentation Development Quality assurance testing Paper and manual processes are likely the biggest types of internally created system components and they too require: Documentation Internally or externally coordinated development and quality assurance testing 7

Externally Created Components You purchase from outside vendors. Requirements documentation, development and quality assurance is done by a third-party and it is not necessary for your practice to do. You should expect vendors to communicate and deliver: Statements of understanding of ICD-10: compliance date requirements Statements of intended capabilities When test and production changes will be available When and what type of training Installation details enhancement v. replacement products Testing details 8

Tracking Vendors More than likely you work with more than one vendor Important to track vendor information ICD-10 means you may be working with ALL of your vendors Create a vendor spreadsheet to track vendor details: What they do or provide? Specifically for ICD-10! When they will have updates available Contacts Contracts - what's included/not included, when, expiration date Any service level agreements? Costs and when must be paid Keep the lights on vendor? 9

Vendor Readiness Assessment The last question: a keep the lights on vendor is important. All vendors are important, but consider asking yourself what happens if the vendor s solution doesn t work or is late? Could we do it manually for a while? Are there alternative vendors? How well did this vendor perform during a past transition or promised enhancement? Did the installation go as expected? Did you get the support and training you needed? New vendors are an unknown may need references or request information/delivery sooner to feel good because of no history. 10

Capabilities Are Important You have needs! It s vital to match your practice s needs with vendor capabilities. Put together your practice s needs, expectations and concerns, then you can assess vendor responses, statements and actual deliverables. 11

Sample Needs List How are ICD-10 codes entered in my system? How are ICD-9 and ICD-10 codes distinguished from one another when entering information? How are ICD-9 and ICD-10 codes distinguished from one another in reporting? Are any ICD-10 edits based on 10/1/2014? How are any analytics handled? How do I continue to send ICD-9 to a payer not ready for ICD-10 on 10/1/2014? Can I create claims for testing with a future date? 12

Testing Connecting Expectations Vendor capabilities, training and timelines are critical when considering implementation and testing. Need to know WHAT to test. Need to know WHEN to test. Need to know WHERE to test. Need to know HOW to test. Need to know WHOM to test with. Need to know IT S SAFE FOR PRODUCTION 13

Testing Goal Prove that a process and then a system works and meets requirements 14

Testing and ICD-10: Clinical Clinical equivalency Coding must correctly and accurately represent information contained in medical documentation Clinical documentation improvement, reviews, audits are critical Consider nuances of equivalency based on medical documentation v. ICD-9 mapping 15

Testing and ICD-10: Financial Financial neutrality (e.g. predictability, consistency) May not be possible to maintain 100% neutrality Review/testing goal is to understand legitimate changes in reimbursement that may happen when accurate coding is used 16

Testing and ICD-10: Operational Operational readiness Systems and their components whether or not they are administrative, clinical, people, paper, manual, or electronic must be ready for ICD-10 17

Testing and ICD-10: Phases Like with previous transitions, there are two primary phases: Internal Level I, using CMS terms External Level II, using CMS terms 18

Internal Testing Level I Internal focus Ensure that internal processes work Includes business process, paper, and electronic components Test individual components separately as much as possible Once individual components work as expected, begin to link individual components that make up an entire process together to test that the overall system functions correctly. If necessary, when external partners are not or cannot be involved, you will need to pretend the external partner/vendor is involved. 19

Internal Testing Level I Software testing is a significant part of Level I testing. Expect your vendors to supply such things as: recommendations on when to install instructions and training descriptions of extent and scope of change new hardware requirements dependencies on other software changes some systems are more open than others It is up to you to assess capabilities with your needs this is the time to ensure they are met. 20

Internal Testing Level I Ensure that you have carefully considered your needs and that these are addressed and tested, for example: Use of both ICD-9 and ICD-10 code post transition. One or more payers not ready for ICD-10 on the transition date. Handling up to 12 diagnosis codes on a claim. Updated EMR dual code use and templates. New or replaced software especially if you have a new vendor will take much longer to test and understand. Ideally, you have a dedicated test system. If not, you may want to ask and rely on vendor testing to a greater extent. Ask! 21

Internal Testing Level I Don t forget to test necessary changes made to your clinical processes: Include clinical documentation, coding and coding audits as a part of your internal testing plan to ensure your process works. Test updated Superbills, patient statement, EMR templates. Depending on the level or degree that external partners can test, it may be essential to have clinical changes including medical documentation tested and in place before starting external testing. 22

Internal Testing Level I Working with 2014 delivery dates May wish to follow OTHER s testing results Rely on vendor s documented testing results Insist on vendor service and support availability should there be an issue 23

External Testing Level II External focus: Ensure that partner s processes work as expected Includes business process, paper, and electronic components As with internal testing: Test individual components separately as much as possible Once individual components work as expected, begin to link individual components that make up an entire process together to testing the overall system functions correctly. Potential external testing partners: Labs Pharmacies ACO partners Health plans Clearinghouse 24

External Testing Level II Understand external testing partner s: Access to test system: When, who and how Test requirements and expected outcomes Method of reporting results Details of expected differences between test and production environments 25

External Testing Level II Make sure to keep: Contact information Logs and documentation for future training Process flow change reasons Outline of how you did what you did and whether or not it worked Good idea from time-to-time to look at the big picture Tweaks or manually changing things may cause or force something to work, but make sure the tweaks and changes represent how interdependent data flow will actually work in production. 26

Putting It All Together: Scenarios Most conditions and procedures seen and handled today will also be seen after the transition date. Mix of patients, conditions, procedures will be similar Same health plans, government requirements and entities Exceptions might be those enrolled in ACO or other initiatives Therefore, we can: Model today s facts and experiences Review and test these in a mock or test ICD-10 world This is known as Scenario Testing 27

Scenarios Can be defined in many ways to model different ways of looking at today s world, for example: Diagnosis used the most (i.e. volume) Diagnosis involved in complex conditions Diagnosis affecting cost or reimbursements Quality measurement and reporting Case mix Fraud and abuse compliance Contracting terms Common clinical conditions And, of course, hybrid or mixed scenarios 28

Scenarios Definition to Action Once defined, walk through the scenarios with the systems and people from beginning to end Beginning = point of request for service, including: Request for service, patient registration Clinical documentation and coding Billing, reimbursement, payment and denial processing Public health, quality and analytics reporting Scenarios should be as real as possible and include everything that is typically involved Authorizations and referrals Medical policy review 29

Double and Dual Terms used to describe different approaches to coding testing/training Dual coding = adding both ICD-9 and ICD-10 codes simultaneously to the record. Double coding = coding the record using ICD-10 AFTER it s already been coded for ICD-9. Recommendation: to avoid any confusion over approach definitions, always ask for clarification 30

Challenges Not everyone/everything will be ready. Don t fall into this category: test internally and externally where possible. During testing you may discover some issues, which hopefully can be resolved prior to the transition. Testing will not eliminate all problems unexpected things will still happen. 31

Challenges Not all external partners will have the ability to test Will have to take the partner s word for it that their solution will be ready Document this and include where/who provided details 32

Tips Apply what was learned from past transition experiences: Focus your efforts on areas where you had issues before Insist on documentation, timelines, SLA language, etc. from partners who struggled previously Test to the best extent possible, then DOCUMENT how you expect something to work and CONFIRM 33

Tips Monitor what you tested to ensure it works as expected don t assume production works as it did when tested. Understand your patient and member population and your current ICD-9 usage thoroughly. Keep staff and management up to date with dates, testing expectations, transition and production efforts. 34

Testing and Implementation Planning Eliminate as much of the unknown as possible. Quickly address the unexpected issues that arise post-transition. Test so you know whether or not your internal systems work. Software requires testing, but so does clinical, financial, manual, and paper systems (these all use diagnosis codes) 35

Resource: ICD-10 Hub (www.icd10hub.com)

ICD-10 Industry Resources CMS http://www.cms.gov/medicare/coding/icd10/index.html CMS: Latest ICD-10 News http://www.cms.gov/medicare/coding/icd10/latest_news.ht ml Final Rule http://www.gpo.gov/fdsys/pkg/fr-2012-09-05/pdf/2012-21238.pdf ANSI X12 Website http://www.x12.org/ 37