Lessons Learned from CMS ICD-10 Acknowledgement Testing Week

By Juliet Santos, MSN, CCRN, FNP-BC
Original story posted on: March 17, 2014

On March 3-7, the Centers for Medicare & Medicaid Services (CMS) conducted a highly anticipated and critically needed ICD-10 National Testing Week via all the Medicare Administrative Contractors (MAC). Providers, clearinghouses, and others participated in the first-ever ICD-10 claims acknowledgement testing. This was a major milestone on the ICD-10 implementation timeline.

The primary purpose was to ensure that claims can be processed successfully by the providers, then passed along to the clearinghouses and then on to the Medicare system. The secondary purpose, albeit unintentional, was to provide an “early win” for all participants.

Although narrow in scope, the exercise accomplished something that was just as valuable, if not more valuable, than the technical testing. The CMS ICD-10 National Testing Week affirmed the efforts of the majority of Leidos Health clients and staff that they are indeed on the right track and that ICD-10 is challenging, but surmountable.

This also showed that CMS has the infrastructure to receive a variety of high-volume, high-dollar claims. Although the test was not truly end-to-end, participants achieved a major milestone simply by participating and receiving a confirmation that their claims made it to the CMS system through the MACs and clearinghouses.

The testing week was not intended to replace internal and external testing exercises, nor was it held for the purpose of assisting medical billers and coders in preparing their ICD-10 claims. With most Leidos Health clients, the national testing took from a few hours to a couple of days. The CMS National Testing Week was simply an acknowledgement technical test; it was not intended to verify connectivity to the MACs nor to ensure the full capabilities of provider systems in handling ICD-10 codes.

Tracking Client Outcomes

As a major player in the healthcare consulting arena, Leidos Health monitored the experiences of its clients and tracked high-level outcomes through an informal and rapid query process. The informal query focused on the breadth of client preparation and registration experience, clarity of direction and information, simplicity of processes, success rates and outcomes, and impacts on the providers’ testing confidence.

Six Leidos clients participated in the query process, with respondents ranging from professional groups to large healthcare systems. Five of the six organizations received swift confirmation that their claims were received successfully by the MACs. The 277/999 confirmation rates were fairly quick, with some receiving responses in just a matter of hours from the time of submission. None experienced file rejections.

Most organizations prepared as early as possible once learning that CMS would conduct this industry testing exercise, conducting a testing kickoff meeting one to three weeks prior to the acknowledgment testing. Several of the organizations tested both professional and institutional claims for a variety of high-volume/high-dollar DRGs, with the average submitting 25-50 claims.

Lessons Learned During the CMS ICD-10 Testing Week

One hospital system’s configuration involved five major solutions: a widely used electronic medical record (EMR) system, an encoder tool, a diagnosis grouper, a billing system, and claims enhancement software. Each system passed unit testing flawlessly. However, since this test was the hospital’s first attempt at integrated testing in which a claim was created from a patient encounter, there were multiple configuration issues detected when trying to interface information from one system to another.

The provider determined that the configuration glitch was most likely due to insufficient documentation from each vendor. Each vendor needed to provide more detailed instructions on how to configure the communication between systems in order to fulfill and pass integrated testing.

Although claims were finally successfully submitted, there were important revenue cycle gaps identified in the process of patient account creation and billing that required immediate, high-priority remediation. Once these issues are fully resolved, additional testing cycles will be added to the system’s testing plan until defects are cleared.

Although five of the six participants experienced success, one large provider’s hospital claims were submitted through a major clearinghouse to Novitas, a MAC, the day before the official testing began on March 2 – but it has not yet received the 277/999 acknowledgement. This entity continues to monitor the status through its clearinghouse.

However, this same entity submitted professional claims through another major clearinghouse trading partner to Novitas on March 5. It received acknowledgement confirming that this particular batch was received. The clearinghouse also received CMS claim edits over the weekend. The entity currently is working to determine whether it or the clearinghouse caused the processing errors. After the internal audit is complete, each provider utilizing this clearinghouse will be notified of its test results by email.

Other issues experienced by a major healthcare system involved the ICD-10 Medicare Test files being rejected initially due to the fact that they had invalid MCR identification numbers. Although the provider was informed that this was not ICD-10-related, their clearinghouse corrected the ID numbers, resubmitted the files, and successfully transmitted the claims.

The majority of provider participants found that registration was simple and easy. However, initially it was not clear that only providers that submit directly to the MACs needed to register on the MAC website. Providers submitting claims through clearinghouses did not need to register with the MAC because this particular clearinghouse registered all of its clients.

Other noteworthy responses to the Leidos Health informal query are included below:

Q: Were you given enough directions, guidance, and preparation information?
A: Different MAC websites provided different levels of information and guidance. I found myself looking at other websites besides my own MAC’s website. I (the ICD-10 PM) had to synthesize all information extracted from the various websites. Clearly, we needed more information besides that provided by our MAC alone.

Q: Did you experience any issues?
A: We have not received any feedback on the hospital claims submitted. A third major clearinghouse, also our trading partner, notified us that they were not participating in the CMS test, so a portion of our physician claims could not be included in the CMS testing.

Q: What did you do to prepare for the CMS Testing Week?
A: On the hospital side, we identified previously submitted Medicare claims and then HIS re-coded; PFS re-processed, and resubmitted them. On the physician side we also used previously submitted ICD-9 claims but used a clearinghouse tool to re-code them for inclusion in a test batch.

Q: How far in advance did you prepare to test with CMS?
A: Approximately two weeks to prepare test claims.

Q: What were the outcomes of your test?
A: We have not received acknowledgement that our test files were received for our institutional claims. We have received confirmation for our professional claims.

Q: Do you have any suggestions for the next CMS testing week?
A: More standardization across the clearinghouses would be helpful. More timely feedback is critical to providers so we could correct and resubmit errors.

Summary

Although the CMS ICD-10 National Testing Week was limited in its scope and duration, Leidos Health clients still found it to be extremely useful and effective in achieving an “early win” for the majority of participants. In future CMS testing, providers plan to utilize other test environments, revenue cycle processes, and actual trained staff to better replicate what really happens in production.

Overall, the majority of participating providers that responded to the query indicated that the registration claims submission process was simple, easy to follow, and inclusive of enough information to get started. However, it was evident that not all MACs provided the same level of information. Some were thorough but posted insufficient guidance, which led providers to spend time searching multiple websites for additional information.

More opportunities for testing are clearly needed, and specifically testing that encompasses a broader scope, longer duration, and more participants. Providers are requesting more direct information on adjudication, paid rates, denials, and pending rates. Others would like more feedback on coding accuracy.

Lastly, it is evident that providers must conduct internal testing to fully leverage any and all CMS testing opportunities. Although not required for participation, program directors should guide their teams to ensure that user agreement testing (UAT) is conducted and passed prior to further testing with CMS. This scenario is best to determine where defects lie – either on the side of providers or on the side of external trading partners. Once providers pass UAT, if testing does not work using standard test data, the defect may very well be on the side of external trading partners. All of these are worthwhile notions to ponder as we embark full steam ahead on ICD-10 testing with as many trading partners as possible, and as CMS engages the industry in more testing opportunities. 

About the Author

Juliet Santos is the principal ICD-10 consultant for Leidos Health, which specializes in solving complex problems across the healthcare continuum. Santos formerly was EVP of Lott QA Group and assisted with the creation of ICD-10 National Testing Platform.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.