ICD-10 Testing Scenarios: What medical practices need to know

Carl Natale
by Carl Natale

Just like in school, you need to know what kind of test to expect and what to expect do do well.

The Centers for Medicare and Medicaid Services (CMS) explain testing scenarios and test data in its  ICD-10 Implementation Guide for Small and Medium Practices. The following is from the implementation guide

Before you begin testing, you need to "study:"

  • Identify testing workflows and scenarios for your practice that apply use cases, test cases, test reports, and test data.
  • Identify when your practice will be able to run test claims using ICD-10.
  • Develop a project plan that recognizes dependencies on tasks and resources. The plan should prioritize and sequence efforts to support critical paths.

Test Data

This is the type of data that needs to go into your ICD-10 testing scenarios:

  • Validate (data validation)
  • Trigger errors
  • Test high risk scenarios
  • Test volume
  • Test all types of domains and categories
  • Simulate a standard environmental model over time
  • Includes data content to test all aspects of the business intent
  • Test comparisons, ranking, trending variation, and other key analytic models

Unit testing/basic component testing

Confirms that updates meet the requirements of each individual component in a system. Providers will first need to test each component updated for ICD-10 coding.

  • Unit testing should verify that
    • Expanded data structures can store the longer ICD-10 codes and their qualifiers
    • Edits and business rules based on ICD­ 9-CM codes work correctly with ICD-10 codes
  • Since reports frequently use diagnosis and procedure codes, testing report updates are critical. Critical report elements to evaluate include:
    • Input filters: Do all filters produce the anticipated outcome?
    • Categorization: Do categories represent the user’s intent as defined by aggregations of codes
    • Calculations: Do all calculations balance and result in the anticipated values considering the filter applied and the definition of categories?
    • Consistency: Do similar concepts across reports or analytic models remain consistent given a new definition of code aggregations?

System testing

Verifies that an integrated system meets requirements for the ICD-10 transition. After completing unit testing, providers will need to integrate related components and ensure that ICD-10 functionality produces the desired results.

  • Plan to test ICD-based business rules and edits that are shared between multiple system components
  • Identify, update, and test all system interfaces that include ICD codes

Regression testing

Focuses on identifying potential unintended consequences of ICD-10 changes. Test modified system components to ensure that ICD-10 changes do not cause faults in other system functionality.

  • The complexity of ICD-9-CM to ICD-10 code translation may result in unintended consequences to business processes.
  • Identify these unintended consequences through varied testing scenarios that anticipate risk areas.

Non-functional testing-performance

Performance testing includes an evaluation of nonfunctional requirements such as transaction throughput, system capacity, processing rate, and similar requirements.

  • A number of changes related to ICD-10 may result in significant impact on system performance, including increased:
    • Number of available diagnosis and procedure codes
    • Number of codes submitted per claim
    • Complexity of rules logic
    • Volume of re-submission due to rejected claims, at least initially
    • Storage capacity requirements

Non-functional testing-privacy

Federal and state legislation defines specific requirements for data handling related to conditions associated with mental illness, substance abuse, and other privacy-sensitive conditions. To identify these sensitive data components or conditions, payers often use ICD-9-CM codes.

Update the definition of these sensitive components or conditions based on ICD-10-CM

Internal testing (Level I)

Level I compliance indicates that entities covered by HIPAA can create and receive compliant transactions.

  • Transactions should maintain the integrity of content as they move through systems and processes
  • Transformations, translations, or other changes in data can be tracked and audited

Key considerations:

  • Database architecture
  • User interfaces
  • Algorithms based on diagnosis or institutional procedure codes
  • Code aggregation (grouping) models
  • Key metrics related to diagnosis or institutional procedure codes
  • All reporting logic based on diagnosis or institutional procedure codes

External testing (Level II)

Level II compliance indicates that a covered entity has completed comprehensive testing with each of its external trading partners and is prepared to move into production mode with the new versions of the standards by the end of that period.

  • Establish trading partners testing portals
  • Define and communicate transaction specification changes
  • Determine the need for inbound and outbound transaction training
  • Determine the need for a certification process for inbound transactions
  • Determine the process for rejections and re-submissions related to invalid codes at the transaction level
  • Determine if parallel testing systems need to be created to test external transactions

Error Testing

Testing will result in errors. Correcting the errors before the go-live date is the goal of the testing phase. Practices should include the following in their error-testing plan:

  • Multiple testing layers to support various iterations of re-testing in parallel tracks
  • Effective detection and repair of blocking errors that limit testing activities
  • An error-tracking system with standard alerts to report to stakeholders
  • Prioritization model for error remediation designed to focus on business-critical requirements
  • Set of acceptance criteria
  • Model for reporting known issues
  • Developing a schedule for fixing known issues in the future

 Testing partnerships

You need to work with various organizations outside your medical practice:

Vendors: Coordinate directly with your vendors as necessary to support testing execution and issue resolution.

Payers: Payers are critical to the financial viability of your practice. Denials or payment delays may result in a substantial decline in revenues or cash flow. Payers may struggle with the ICD-10 transition due to the significant system changes needed to support policies, benefit/ coverage rules, risk analysis, operations, and other critical business functions impacted by this change. Payer testing should identify and resolve any issues prior to go-live.

  • Determine if the payer has educational programs and collaboration efforts to support providers through the transition
  • Use the high-dollar, high-volume, high-risk scenarios that your practice has created to produce test claims
  • Work with payers to develop test scenarios to conduct end-to-end testing, specifically identifying payment results
  • Communicate coding practices and scenarios to payers to build better relationships throughout the testing and transition process
  • Identify communication processes to identify and correct issues early with payers

Hospitals: Test information exchanges with hospitals to ensure appropriate handling.

Health information exchanges: Test all information exchanges for critical operations to meet inoperability standards.

Outsourced billing or coding: Test outsourced coding and billing operations with defined clinical scenarios to make sure these business operations continue as expected.

Government entities: Local and national government entities may require reporting for a variety of purposes including:

  • Public health reporting
  • Quality and other metric reporting related to meaningful use
  • Medicare and Medicaid reporting and data exchange
  • Other mandated or contractually required exchange of information around services and patient conditions