Drg Map
Remediation strategy oriented ICD-10 Testing- A Prescription
The transition to ICD-10 is going to be a mission critical project for healthcare industry players. The success and failure of this project will be heavily reliant on exhaustive testing activities, both within the organization as well as with the external partners. In addition to a traditional testing, organizations need to strategize their testing activities to handle the different levels of preparedness of their trading partners as they may transition to ICD10 at different times and that would in turn impact the process you deploy for the ICD-10 rollout. The ICD10 compliance principle adopted by an organization may require its own specialized testing strategy; this article identifies the possible approaches an organization might take towards ICD10 compliance and recommends forms of testing likely to yield the best results -
I. Remediation & Replacement: A complete amendment to upgrade all the impacted applications to ICD-10. This approach is certain to bring a significant reengineering of the existing business processes. One will have to draw new contracts and redefine fee schedules. The existing business rules for bundling/unbundling, fraud detection, up-coding will be revisited and remodeled. The risk stratification, predictive modeling algorithms in medical management will undergo major change. All these will be either through internal customization, vendor upgrades or replacing system operations via outsourcing.
Testing in this case will be focused more towards validating the newly developed/changed business processes, workflow, interfaces, etc. The focus of testing here is-
- High: Integration testing, unit testing, functional testing
- Medium: End to end testing
- Low: Regression testing
II. Hybrid: This principle will be predominant among those organizations who have already evaluated their trading partners preparedness towards the ICD-10 compliance & have also estimated the need for un-mutable historical data for analytical purposes. In this scenario, organizations might maintain dual systems and create two versions of the same business processes i.e. one for ICD9 and other in compliance to ICD10. This in my opinion is going to be highly unlikely and difficult to maintain, as this will increase the operational complexity and create an imbalance in the financial matrices.
However, in certain instance this strategy can be beneficial too. Organization can leverage to initiate “Sand-Box testing” for their ICD-10 upgraded system & process, using the production data in a controlled environment. This will facilitate readiness assessment, acceptance status of the upgraded products & re-engineered processes.
The test strategy for the ICD-10 centric business processes will be the same as for ‘Remediation & Replacement’. Regression testing will be very important for the unchanged part of the business processes. End to end testing will be of medium focus. Careful separation of the new and existing processes needs to be ensured for testing and some boundary cases should be included to ensure that for inputs of ICD9 and ICD10 the requests are redirected accurately.
III. Neutralization: Insulating the ICD-9 processing systems from ICD-10. Potentially, it’s a play with forward & backward crosswalk. The existing business process will mostly remain unchanged or will change minimally with the introduction of a crosswalk.
In some cases organizations may be alright to use a frequency based crosswalk (high dollar associated codes, most commonly referred codes across LOBs and etc.) such that they may create a static map to remain payout neutral, whereas in some cases it might be necessary to use a clinical crosswalk to obtain the closest clinical match. For example, in claim adjudication system a frequency based mapping may be acceptable. But, for fraud detection or medical management such a map will not be suitable. Instead a clinical mapping may be more appropriate.
Crosswalk induced neutralization approach is sure to vary for every organization and consequently the testing of this will have organization specific variance. At a high level crosswalk testing will be focused just to –
- authenticate the code conversion
- validate the new format
But, this will likely not be so simple. Crosswalk testing needs to be based on-
- where and how the crosswalk is implemented
- how accountable is it for transactions that touch multiple downstream processes, and
- how important is it from a financial impact to the organization.
The test output needs to be further analyzed to substantiate the clinical accuracy of the converted code (as in disease or case management), the accuracy of audit trails that account for what got crosswalked and the ability to track back the source code and validate the financial aspect of the crosswalked data (applicable for reimbursements) through DRGs.
In this case regression testing becomes very important since the business processes remain unchanged. Integration testing will not be as heavily used, but a medium priority. However organizations need to make sure that the test cases incorporate all the possible inputs that will thoroughly test the maps. Again, boundary and negative test cases becomes important to ensure right operation of each kind of map to complete the business process correctly. For example- create a test case where the ICD code may be borderline case for clinical mapping (e.g. in up-coding, bundling of services, disease based member stratification), but will be routine for the downstream process (e.g. claim payment which may use frequency maps).
End to end testing will be important since the outgoing transactions needs to refer back the ICD10 codes (stored from incoming transaction).
IV. Mix and match: This is the likeliest scenario where for some business processes an organization will use the ‘Remediation and replacement’ i.e. rewrite the business processes and for some other business processes they will opt for the neutralization and not a hybrid approach.
Testing types will be similar as mentioned for remediation & neutralization scenario, but the additional thing to take care of is to create smart test cases which will test the routing part individually as well as in combination (i.e. boundary conditions and combinations). For e.g . Create a combo test case in which an ICD code may not be a boundary case for ‘Remediation and replacement’ but will be for an upstream or downstream process which uses ‘Neutralization’
The above discussion is an attempt to provide insight on how organizations can approach for ICD-10 testing based on their remediation principle. The task is complex, needs careful planning and co-ordination within the organization, among vendors, and trading partners. Testing activity is sure to be humongous considering all that for NPI and 5010 put together, such a level of testing will be unprecedented for the US healthcare IT.
Map scouting with Google Earth – Basic mapping and hybrid maps
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