Practice Makes Perfect: ICD-10 testing strategies for physician practices

In June, MGMA released the results of a questionnaire that ranked members' most pressing practice-management challenges. In this edition of "Practice Makes Perfect," we'll tackle No. 6 on that list: Preparing for the transition to ICD-10 diagnosis coding.

I spoke recently at the MGMA 2013 Annual Conference about the transition to ICD-10. Many attendees echoed recent MGMA research that industry readiness for ICD-10 is lagging. Since this transition is expected to be challenging for medical practices, it is important to develop and implement an effective testing approach. The focus should be on successfully completing each stage in a timely manner to avoid, as much as possible, claim-submission and adjudication issues after the Oct. 1, 2014 compliance date.

Completion of individual component testing, system testing of integrated components and performance testing of all components must be accomplished before external testing. Typically, this will be software used for practice management, billing and electronic health records. Practices might employ additional specialized software that uses diagnosis codes for use in clinical trials, research or other practice operations that will also need to be modified or replaced.

Once the new or revised software is in place, practice professionals will need to work with their vendors to ensure that all affected staff have received training and conduct tests to ensure that the new codes can be generated. Many of these tests will be similar to those performed for other IT changes that practice professionals have conducted for previous standards, such as HIPAA Version 5010 and the National Provider Identifier. This testing is usually conducted with the assistance of vendors, and it involves successfully generating ICD-10 codes in your clinical and administrative systems. However, in the case of PM systems, testing should include the ability to produce both ICD-9 and ICD-10 codes on transactions.

Although typically conducted after your software has been modified to permit the use of ICD-10 codes, workflow testing can begin with staff even if IT systems are not ready for the new codes. Workflow testing sets the ICD-10 transition apart from many of the IT changes your practice has experienced in the past. With ICD-10, coders must rely on the clinical documentation being complete in order to assign the appropriate diagnosis code. Thus, clinical staff must be trained to include the correct level of documentation at the time of the patient encounter to provide sufficient coding support and to avoid introducing into the revenue-cycle workflow the need for post-visit communication with the patient to fill in documentation gaps.

A number of options are available to ensure that your practice's clinical workflow is ready for ICD-10. First, it will be extremely helpful to identify the most common clinical scenarios used in the practice. From your vendor, clearinghouse or internal billing team, identify the top 25 to 50 diagnosis codes successfully submitted; the top 25 to 50 claims using “unspecified' ICD-9-CM codes; and the top 25-50 claims that were rejected or were pended because of insufficient clinical documentation

Once you have established a baseline set of clinical scenarios, the next step is to work directly with your clinicians to ensure that appropriate documentation is being captured. This can be accomplished by reviewing previously adjudicated claims to determine if an appropriately granular ICD-10-CM code could be assigned based on the available documentation. Another option is “dual-coding” current clinical encounters—assigning ICD-9-CM codes and virtually assigning ICD-10-CM codes to claims being produced.

Once the organization's internal IT systems are fully ICD-10 upgraded or replaced and working as predicted and that clinicians are well-versed in any new documentation requirements, practice professionals can begin to initiate testing with external partners.

For many practices, the clearinghouse will be an important external testing partner. Communicate with your clearinghouse as soon as possible to determine if and how they will be testing claims and other transactions, and what ICD-10 services and resources they are offering.

Testing with health plans might prove to be more challenging. Medicare's recent announcement that it will not be testing with physician practices has added a new layer of uncertainty to the external testing process. Practice professionals will want to identify, at a minimum, the health plans that account for the majority of their reimbursements and determine if and when they will be testing ICD-10 claims. It is critical to identify health plans' ICD-10-specific payment policies with an emphasis on alterations to payment, acceptance of unspecified codes and new or revised documentation requirements.

Health plan testing should be conducted with two goals in mind: to determine whether the health plan will accept and pay the ICD-10 coded claim; and if the change to ICD-10 will affect reimbursement levels.

For physician practices, testing will be a critical component to a successful migration to ICD-10. Failure to fully test any one of these stages puts the organization at risk for catastrophic cash-flow disruption after the compliance date because of delayed or denied reimbursement.

To download a guide to preparing for the transition to ICD-10, visit the MGMA website.

Robert Tennant