Standardizing Testing: The ICD-10 National Pilot Program

Transcription

1 Standardizing Testing: The ICD-10 National Pilot Program Tuesday - June 18, :30-2:45 PM

2 Speakers Lisa Gallagher, BSEE, CISM, CPHIMS Vice President, Technology Solutions HIMSS Dean Cook Infrastructure Services Sr. Advisor National Government Services, Inc. Jim Daley Director, IT Risk & Compliance, BlueCross BlueShield of South Carolina Chairman, WEDI Kari Gaare Health Insurance Specialist, Administrative Simplification Group, Office of E-Health Standards and Services, CMS

3 Agenda HIMSS/WEDI ICD-10 National Pilot Program CMS End-to-End Testing Process Q&A

4 HIMSS/WEDI ICD-10 National Pilot Program Jim Daley

5 Learning Objectives Describe the ICD-10 National Pilot Program and its purpose List the program's goals, objectives and participants Discuss how the industry can utilize the information derived from the outcomes of pilot testing Discuss pilot test finding to date

6 Leadership Team HIMSS and WEDI co-lead the ICD-10 National Pilot Program with the following serving as key leaders and contacts: Joe Miller Director of E-Business AmeriHealth Mercy Jim Daley Director, IT Risk & Compliance BCBS South Carolina; WEDI Chairman Juliet A. Santos, MSN, CCRN, FNP-BC Senior Director HIMSS Business-Centered Systems

7 The Problem Most HIT compliance initiatives of the last ten years have been delayed! (4010, NPI, 5010, Administrative Simplification) Impact to our Industry of Delays are: Increased costs to vendors, providers, health plans and other trading partners Postponed intended benefits Reduced confidence in the regulatory process

8 How Do We Prevent Another (Costly) Delay in ICD-10? G7 Industry Leadership Meetings (April/July 2012) Call to Action Report (August 2012) Achieve Broad Stakeholder Support for an ICD-10 Pilot Program with End to End Testing of Business Processes Accelerate the Readiness of Vendors Supporting Health Plans, Providers, and Other Vendors Significantly Expand Education Focused on Independent, Physician Group Practices. Recognize the Cooperating Parties (CMS, NCHS, AHIMA, and AHA) and AAPC for accurate and consistent coding Workgroups Established HIMSS supports ICD-10 member education regardless of date--will support our members until completion

9 Goals for ICD-10 Pilot Program Identify standard test cases that can be utilized by the general healthcare industry free of charge Provide early Pilot Tests that can demonstrate the feasibility of ICD-10, surface issues early, and create models for future testing Provide resources and guidance to providers during the implementation phase through Solutions Centers (based on successful outcomes of Pilot Phase and project funding) Publish incremental data on testing outcomes, best practices and to share relevant new findings Build collaboration among participants, build mutual trust through sharing of ideas and best practices Enhance the efficiency of the testing process, thus reducing the cost of trial and error

10 The Testing Challenges Agreeing on test data Establishing matching databases Coordinating schedules Conducting testing Validating results Late uptake testing deluge Can t do it all at once

11 HIMSS/WEDI NPP Work Groups Project Scope - Responsible for identifying the parameters of the ICD-10 National Pilot Program and its work group (define what is covered within the pilot and what is not) Organization - Creating the structure and functions of proposed Regional Solution Centers Finance/Budget - Accountable for budget development/management and funding opportunities Testing Scenarios & Coding - Identify the test cases and receive de-identified medical records from participants Testing & Methodology - Develop the overall parameters for testing

12 The Testing Challenge Many to Many Relationships - Multiple Test Sets and Schedules PMS/HIS Vendor Provider Provider Direct Payer Payer Vendor Provider Payer Vendor Provider Clearing house / billing services Payer Vendor Provider Payer

13 Testing Solution Standard Needs to be circular relationship and include Medicare and other key stakeholders Vendor- A/P provider Provider/ Practices /Physicians Payer- Medicare Vendor Vendor Standard Test Scenarios Provider Provider Standard Test Scenarios- Vendor/ Clearinghouse Payer Payer Provider Payer Vendor Provider Payer

14 Scope of Pilot Testing Pilot Tests with limited end-to-end testing starting from patient care to plan adjudication Pilot Tests Using Standard Cases Trading Partner Testing Using Standard Cases Include Medicare/Medicaid as early as possible in the pilot testing Identify Coding challenges through testing using standardized data sets/cases

15 Shared - Test Cases

16 Value of Standard Cases Enables a base level of testing Vetted through participants De-identified Applies common threshold values Identifies best practices in each sector

17 Testing Cases Test Cases Supported with Clinical Documentation Coded by experts Large and small providers level of technology sophistication and different care settings, multi specialty/single specialty, reimbursement model Large and small health plans

18 Approach to Test Case Creation Payers Providers Vendors Others Clearinghouse Documentation Format Candidate ICD-10 Test Cases Test Case Collect Test Cases and Clinical Documentation Review Committee Pilot Testing

19 Pilot Phase Emphasis on Clinical Relevance Clinical Tests Technical Tests

20 Standard Test Case Set Evolution Pilot tests will offer opportunity to refine Test Cases Final set published on HIMSS ICD-10 Playbook site Can be re-used for final testing as well Public domain, but vendors can use them and add to them Will work for large and small providers Establishes minimal testing threshold

21 Testing Stages April July 2013 August Dec Pilot Tests with Initial Test Cases Planned effort Test of initial standard cases Do as much end to end testing as possible, recognizing that some processes may not be finalized Provides feedback used to refine standard cases Independent Industry Testing with Standard Test Cases Standard cases used by industry stakeholders Include as many stakeholders as possible in an end to end case Provides feedback used to refine standard cases Cooperative Exchange Support Full Industry Testing with Standard Test Cases Plus Others Additional testing test cases used by industry stakeholders as well as Standard Set Testing organized by stakeholders themselves Cooperative Exchange Support

22 Participating Entities HIMSS, WEDI, CMS, NGS, AHIMA, AAPC, HBMA, the Cooperative Exchange There are 90 participating organizations There are 218 individual participants from those organizations Those organizations represent providers, clearinghouses, vendors, health plans, government agencies, not-for-profits, consultants and hospitals

23 Progress to Date (To be reported at conference) Participant counts Current status Lessons learned Over 250 organizations involved Test cases to be published by end of July Outcomes report expected in September timeframe ICD-10 PlayBook

24 HIMSS ICD-10 National Testing Program Contacts Mark Lott President Lott QA Group Stanley Nachimson Principal, Nachimson Advisors LLC Co-chair, HIMSS ICD-10 Task Force, Co-chair, WEDI ICD-10 Testing SWG

25 UnitedHealthcare ICD-10 Remediation & Testing Approach Shirley Reynolds ICD-10 Business Test Director UnitedHealthcare, Provider Regulatory Programs June, 2013

26 ICD-10 Remediation & Testing Guiding Principles UnitedHealth Group is committed to: Full regulatory compliance. Systems will accept new ICD-10 transactions (while continuing to accommodate ICD-9 coded claims for service dates prior to the regulatory compliance date) without data mapping or transformation. Perform extensive internal testing to verify predictable processing outcomes: Clinical Integrity: Ensure alignment with industry code mapping and consistent clinical review decisions. Benefit Neutrality: Ensure transparent benefit administration for members and providers across both code sets. Revenue Predictability: Perform internal analysis and collaborate with selected external providers to assess the impact of ICD-10 code selection on DRGs. Support health care providers in their readiness efforts. Industry assessments indicate a risk that not all providers may be ready to generate ICD-10 transactions by the compliance date. UnitedHealthcare has a dedicated communication effort to advise providers on ICD-10 preparation steps and to provide resource materials. Collaborate and test with providers and other business partners, including Testing with selected providers to identify areas at risk for unpredictable results and define strategies to improve the accuracy and predictability of production transaction outcomes. End-to-end testing with limited providers, practice management/coding vendors and clearinghouses to verify transaction compliance, accuracy and predictable payment results. Communicate lessons learned, mitigation strategies and readiness recommendations to our providers via portals and other communication channels.

27 UnitedHealth Group ICD-10 Remediation & Testing Timeline Plan Design System Build & Test Impact Assessment Technical Foundation & Compliance : Application Design, Development & Testing Code Review, Internal Test & Readiness 2014 External Testing & Operational Readiness Clinical Code Review & Loads Focus: Internal System, Staff & Process Readiness Focus: External Business Partner Readiness Assessment, Support & Collaboration Comprehensive Internal Tests End-to-End and Neutrality Training & Operational Readiness Assess & Support Vendor/ Trading Partner Readiness Early Payer/Provider Collaboration (DRG Shift analysis) External Partner Testing Provide Readiness Outreach, Communication and Resources to Delivery-Side Partners

28 ICD-10 External Testing Challenges Health care organizations recognize the need to expand beyond traditional (internal) testing to include External testing with business partners, in order to understand how partner organizations will use new codes in transactions and processing. External testing challenges Requires coordination and schedule alignment between impacted parties: provider, practice management or other vendor, clearinghouse(s), payer. Parties must agree on test content (clinical scenarios, data, expected results). Presents challenges to identify test scenarios that: o Represent realistic provider coding situations (based on medical records), and o Where the expected result (correct assigned ICD-10 codes) should be pre-determined to prevent significant discovery process during testing Organizations must plan for resources to analyze and resolve unexpected test results. The scope and selection of test partners may be limited. Not feasible for. o Providers to test with all payers or Payers to test with all providers o Practice Management/Coding Vendors, Claim Intermediaries and Clearinghouses to test with all customers o Potential delays in organization readiness pose a risk that a high volume of partners may want to test at the last minute (Q3 2014). External end-to-end testing may not be feasible or available to all organizations.

29 Facility- Payer Collaborative DRG Shift Analysis Test Partners: Key Facilities Manual test that allows a Facility & Payer to evaluate coding conditions that generate an ICD-9 to ICD-10 DRG shift Parties agree on a sample of ICD-9 adjudicated claims (all DRG categories) Facility coding staff use original medical records to assign ICD-10 codes. Payer compares original claim DRG to the DRG assigned to the ICD-10 claim. Claims with DRG shifts are analyzed by OptumInsight certified coders and Variations are evaluated jointly by the facility and UnitedHealthcare. External Testing Phase 1 In , UnitedHealthcare partnered with several hospitals to conduct early collaborative testing to evaluate potential DRG shifts UnitedHealthcare performed internal and external analyses to predict ICD-10 coding impact on DRG Shifts, including: Internal high volume automated code translation and detailed analysis. Testing with key Facilities based on ICD- 10 coding from medical records. Preliminary Findings The number of clinically likely shifts was in line with CMS and 3M predictions. As groupers are refined (v28 to v30) DRG shifts are reducing. Facilities with well-trained ICD-10 coders should see comparable DRG assignments in ICD-9 and ICD-10.

30 External Testing - Phase 2 (2014) In addition to participation in the HIMSS/WEDI ICD-10 National Pilot, UnitedHealthcare plans to test with selected external partners. Coding & Claim Payment Validation Test partners: selected Hospitals, Physicians, and other providers (e.g. Home Health, DME, Lab, etc.) 1. Parties agree on medical records (selected from paid ICD-9 claims to provide a basis for comparison). 2. Facility or physician office assigns ICD-10 codes to test cases. 3. Payer engages clinical coding experts to also identify valid coding for test claims. 4. Test claims do not contain PHI and may be exchanged via web or secure Payer adjudicates and returns claim payment result. 6. Provides joint visibility to code assignment and payment of ICD-10 test cases. Limited End-to-End Transaction Testing Test partners: Limited Facilities, Physicians, other providers and vendors, clearinghouses 1. Tests production-like process flows (via test environments) using predefined medical record based test scenarios and data. 2. Requires collaboration among the provider, vendor, clearinghouse and Payer. 3. Provider submits 837; Payer completes test claim adjudication and returns result (835) 4. Validates accurate ICD-10 coding, data transmission, flows, edits, and claim processing outcomes.

31 External Test Objectives Providers have an opportunity to practice ICD-10 coding, using real medical records, as a basis for collaborative testing. Provides an opportunity for payers to verify the accuracy of claim systems using ICD-10 codes selected by providers (vs. internal ICD-10 code mapping assumptions). Assumes code selection and claim payment test results from a selection of the provider population will be extensible to all providers. UnitedHealthcare plans to share findings and recommendations from test efforts with all providers and business partners via provider portals and other communication channels.

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33 End-to-End Testing for ICD-10 June 18, 2013

34 Welcome Presenters: Kari Gaare, Centers for Medicare & Medicaid Services Dean Cook, National Government Services, Inc. 34

35 Topics Why this project is needed What we set out to do What we have completed to date What we continue to do Checklists (High Level and Detailed) Collaboration (ICPs, Listening Sessions) Other collaboration (CMS, HIMSS, NGS, WEDI) More information Questions 35

36 Why this project is needed 36

37 Why this project is needed Past implementation challenges Upcoming regulatory requirements Need for further clarification of terms in ACA January 1, 2014 Compliance date for EFT/ERA standard and operating rules October 1, 2014 December 31, 2013 and December 31, 2015 November 7, 2016 Compliance date for ICD-10 Health plans certify compliance Compliance date for Health Plan Identifier (HPID) 37

38 End-to-end (E2E) testing process Successful implementation Transition to production Implementatio n End-to-end (E2E) testing Level 1 testing Level 2 testing Level 3 testing Regulatory requirement Compliance date 38

39 What we set out to do 39

40 Goals To develop and implement a process and methodology for end-toend testing of the transaction standards, operating rules, code sets, identifiers, and other Administrative Simplification requirements based on industry feedback and participation. To develop an industry-wide Best Practice for end-to-end testing that lays the ground work for a more efficient and less time consuming method for health care industry testing of future standards, leading to more rapid adoption of the future standards. 40

41 Intended outcomes Documents for all industry segments outlining the critical checkpoints needed to ensure compliance. Checklist drafts are published and available and continue to be refined and published. Universal testing process and methodology that can be adopted by all industry segments Included in the checklists that continue to be refined and published. Variation may occur depending on the requirement Framework with definitions for end-to-end testing process, readiness, and compliance. Complete and published. 41

42 End-to-End Testing for ICD-10 June 18, 2013

43 Welcome Presenters: Kari Gaare, Centers for Medicare & Medicaid Services Dean Cook, National Government Services, Inc. 43

44 Topics Why this project is needed What we set out to do What we have completed to date What we continue to do Checklists (High Level and Detailed) Collaboration (ICPs, Listening Sessions) Other collaboration (CMS, HIMSS, NGS, WEDI) More information Questions 44

45 Why this project is needed 45

46 Why this project is needed Past implementation challenges Upcoming regulatory requirements Need for further clarification of terms in ACA January 1, 2014 Compliance date for EFT/ERA standard and operating rules October 1, 2014 December 31, 2013 and December 31, 2015 November 7, 2016 Compliance date for ICD-10 Health plans certify compliance Compliance date for Health Plan Identifier (HPID) 46

47 End-to-end (E2E) testing process Successful implementation Transition to production Implementatio n End-to-end (E2E) testing Level 1 testing Level 2 testing Level 3 testing Regulatory requirement Compliance date 47

48 What we set out to do 48

49 Goals To develop and implement a process and methodology for end-toend testing of the transaction standards, operating rules, code sets, identifiers, and other Administrative Simplification requirements based on industry feedback and participation. To develop an industry-wide Best Practice for end-to-end testing that lays the ground work for a more efficient and less time consuming method for health care industry testing of future standards, leading to more rapid adoption of the future standards. 49

50 Intended outcomes Documents for all industry segments outlining the critical checkpoints needed to ensure compliance. Checklist drafts are published and available and continue to be refined and published. Universal testing process and methodology that can be adopted by all industry segments Included in the checklists that continue to be refined and published. Variation may occur depending on the requirement Framework with definitions for end-to-end testing process, readiness, and compliance. Complete and published. 50

51 What we have completed to date 51

52 What we have completed to date 52

53 Pilot definitions approved Term End-to-end testing Readiness Compliance Definition End-to-End testing is a focused process within a defined area, using new or revised applicable products, operating rules or transactions, throughout the entire business and/or clinical exchange cycle, for the purpose of measuring operational predictability and readiness. The End-to-End testing process should be performed in an environment which mirrors actual production as closely as possible, confirming the validation of performance metrics and analytics (reporting). Readiness is a state of preparedness in which an Entity has completed verification and validation of applicable policies, procedures, guidelines, laws, regulations, and contractual arrangements with expected results. Additionally, entities will demonstrate readiness by completing internal documentation, establishing communication mechanisms and validation with external trading partners, training of appropriate personnel, scheduled deployments, and software migration for each regulatory requirements. Demonstrated adherence to those policies, procedures, guidelines, laws, regulations to which the business process is subject in advance of, by or after the regulatory implementation date. 53

54 Levels defined Level Explanation of purpose 1 The period during which entities perform all of their internal readiness activities in preparation for testing the new versions of the standards with their Trading Partners. When an entity has attained Level 1 compliance, it has completed all internal readiness activities and is fully prepared to initiate testing of the new versions in a test or production environment, pursuant to its standard protocols for testing and implementing new software or data exchanges. 2 The period during which entities are preparing to reach full production readiness with Trading Partners. When an entity is in compliance with Level 2, it has completed some end-to-end testing with external Trading Partners. Key difference between Level 1 and Level 2: Level 2 is done in a production-like environment that may not be exactly a replicate of the production system. 3 The period during which end-to-end testing is performed with external Trading Partners and the Trading Partner is able to operate in production/production-like mode with the new versions of the standards by the end of that period. By production/production-like mode, we mean that entities can successfully exchange (accept and/or send) standard transactions and, as appropriate, be able to process them successfully. Key difference between Level 2 and Level 3: Level 3 is conducted in the same environment that is used when going live and into production. 54

55 Levels and Elements assigned Level 1 is the period during which entities perform all of their internal readiness activities in preparation for testing the new versions of the standards with their Trading Partners. When an entity has attained Level 1 compliance, it has completed all internal readiness activities and is fully prepared to initiate testing of the new versions in a test or production environment, pursuant to its standard protocols for testing and implementing new software or data exchanges. Planning Assessment Design Development Testing Transition Level 2 is the period during which entities are preparing to reach full production readiness with Trading Partners. When an entity is in compliance with Level 2, it has completed some end-to-end testing with external Trading Partners. Key difference between Level 1 and Level 2: Level 2 is done in a production-like environment that may not be exactly a replicate of the production system. Assessment Design Testing Transition Level 3 is the period during which end-to-end testing is performed with external Trading Partners and the Trading Partner is able to operate in production/production-like mode with the new versions of the standards by the end of that period. By production/production-like mode, we mean that entities can successfully exchange (accept and/or send) standard transactions and, as appropriate, be able to process them successfully. Key difference between Level 2 and Level 3: Level 3 is conducted in the same environment that is used when going live and into production. Planning Testing Transition 55

56 What we continue to do 56

57 Checklists 57

58 Industry segments At this time there are five industry segments being addressed in this project. Small Provider Large Provider Payer Vendor-to-Payer Vendor-to-Provider These industry segment checklists are all in continuous development and revision. 58

59 High level documents The High Level End-to-End Testing Documents provide more of an overview than the detailed checklists. There are two high level documents created for each industry segment (ICD-10 and Administrative Simplification). Each High Level End-to-End Testing Document includes a Process Flow chart as a visual aid for the user. These documents are available from the CMS End-to-End Testing web page located at Administrative-Simplification/Affordable-Care-Act/End-to-End- Testing.html. 59

60 High Level ICD-10 End-to-End Testing Documents 60

61 Detailed checklists The detailed checklists are Excel workbooks. Each identified industry segment has a detailed checklist. Within the detailed checklists there are tabs for each of the following: Instructions Definitions Initial Assessment checklist Administrative Simplification checklist ICD-10 checklist Testing Guidance checklist These checklists are available from the CMS End-to-End Testing web page located at Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html. 61

62 ICD-10 End-to-End Testing Checklists Large Provider Payer Small Provider Vendor-to-Payer Vendor-to-Provider 62

63 Collaboration (Industry input, outreach, and participation) 63

64 Industry Collaborative Partners (ICPs) Aetna* American Health Insurance Plans (AHIP)* American Hospital Association (AHA) American Medical Association (AMA) CMS Medicaid CMS Medicare Fee For Service Emdeon Healthcare Billing & Management Association (HBMA) IVANS Medicaid CSG Government Solutions Medical Group Management Association (MGMA) Nachimson Advisors, LLC Providence Health and Services TIBCO Foresight TRICARE UNC Health Care Walgreens WellPoint Veteran s Affairs * Count as one ICP. 64

65 ICP Webinars Participation by invitation; there are 18 ICPs Weekly or semi-weekly webinars (Tuesdays and Thursdays) as needed Review and input forum for the following: Checklists Related materials Q&A from mailbox, webinars, and other special presentations # Sessions # ICPs Avg # registered Avg # attend % Reg vs. attend % 65

66 Listening Sessions Weekly or semi-weekly webinars (Tuesdays and Thursdays); more sessions and other days as needed to meet demand Open sessions; invitation requests via to NGS presentations with Q&A session following All registered attendees receive a copy of the presentation and the related checklists via ; the checklists are also available on the CMS End-to-End Testing web page Listening Sessions are on a break until July 2013 to allow the team to incorporate feedback and suggestions Upcoming sessions will be listed on the CMS End-to-End Testing web page. 66

67 Listening Sessions Listening Sessions # Sessions to date Total attendance Average attendance Small Provider Large Provider 12 1, Vendor Payer Special sessions Total 50 3,

68 Other outreach Questions, comments, and requests via () NGS Surveys Round 1 January 2013 Round 2 March 2013 NGS Listening Session Real Time Polls Began April 16, 2013 Continue when Listening Sessions resume in July

69 Other collaborations (CMS, HIMSS, NGS, WEDI) 69

70 Collaboration CMS/NGS and HIMSS/WEDI collaboration CMS materials will be included in HIMSS/WEDI ICD-10 National Pilot Program HIMSS/WEDI participants will review and provide feedback on the checklists CMS/NGS will review the products and results of the pilot program 70

71 Differences CMS/NGS and HIMSS/WEDI processes CMS/NGS is developing definitions and a description and framework of end-to-end testing for all Administrative Simplification requirements, including ICD-10 HIMSS/WEDI is an actual application of testing specific to ICD-10 Pilot sandbox to play in to test process 71

72 CMS End-to-End Testing Pilot What it does NOT include. A software package or application that will create test claims for the industry Test data to be used by the industry A testing environment or universal testing platform 72

73 CMS/NGS timeline NGS Pilot for End-to-End Testing Phase I Business and Gap Analysis - September 24, 2012 through December 21, 2012 (Complete) Phase II - Development of Pilot Testing (Artifacts, Definitions, Process and Methodology) - December 10, 2012 through June 27, 2013 (approximately six months)* Phase III - Implementation and Quality Assurance is July 1, 2013, and will run through September 23, 2013 (approximately three months)* HIMSS ICD-10 National Pilot Program Early Phase April 2013 through July 2013 Second or Middle Phase August 2013 through December 2013 Third or Late Adopter Phase January 2014 through June

74 CMS/NGS timeline 74

75 More information 75

76 CMS ICD-10 web page located at CMS End-to-End Testing web page located at and-guidance/hipaa-administrative-simplification/affordable-care-act/end-to- End-Testing.html has links to all the checklists. CMS Updates (CMS ListServ) feature is available on all CMS web pages. Submitting your address ensures notification of CMS updates including End-to-End Testing checklists and other related documents. Medscape Education modules link is available from the CMS ICD-10 web page ( RzY2FwZS5vcmcvdmlld2FydGljbGUvNzY1NzU0&ac=401). Note that Continuing medical education (CME) credits are available to physicians who complete the modules, but anyone can take them and receive a certificate of completion. 76

77 Contact information All questions may be sent to Our expected level of service is to respond within one business day Additional contact resources... Resource Role addresses Work phone Cell phone David Carrier Lead BA (207) (207) Dean Cook Advisor/SME (502) (502) Julie McBee BA/POE (317) (317)

78 Questions? 78