Updated on: November 21, 2016

Risk-Based Testing for ICD-10

By Tom Parnon
Original story posted on: May 8, 2015

With fewer than five months to go until ICD-10 implementation, many healthcare providers and payers have not completed testing their health information management systems. In fact, a number of providers, especially smaller institutions, have not conducted any systematic ICD-10 testing. For all providers and payers who do not feel comfortable with the amount of ICD-10 work done thus far, there is still time to complete meaningful testing. To make the best use of the limited time available, QualiTest recommends using a risk-based testing approach.

Risk-based testing is a technique used across the QA industry. It is an effective testing methodology even when there is a lot of time to spare. Test prioritization is required in all software testing efforts. Even if resources are abundant, there is always more testing that can be done. In the case of ICD-10, risk-based testing is the most effective testing approach there is.

When conducting risk-based testing, the first task necessary is to define high-level test objectives and priorities. Then a master test plan should be created to identify the specific workflows to be tested and the approaches to be used. These workflows represent key business processes. In risk-based testing, the most important and potentially impactful workflows are tested first, then the next most important workflows are tested. Testing from highest priority to lower priority workflows is continued until the time and resources allocated to the testing project are consumed.

In the case of ICD-10, the purpose of testing is to mitigate risk prior to the implementation date. The primary risk we are concerned with is negative revenue impact. Claim denials, rejections, and delayed payments are possible. These negative outcomes could cause significant problems. So the goal of risk-based ICD-10 testing is to evaluate those workflows with the highest potential impact on revenue to make sure that systems process data properly and to verify that proper reimbursements will be made in a timely manner.

For most hospitals, MS-DRGs are the primary reimbursement mechanism. Using a risk-based testing approach involves testing the workflows associated with the most commonly seen DRGs and then working down the list. The workflows to be tested typically would include those systems that process the data, from charting through coding and on to billing. Using impact analytics, a hospital should be able to identify priority workflows by considering the diagnosis and procedure codes that historically have contributed to the highest-cost and highest-frequency cases.

Though each hospital has its own unique case profile, there is a high likelihood that a relatively small number of DRGs will contribute to a large percentage of each hospital’s revenues. For example, MS-DRG 470 (major joint replacement of lower extremity) and MS-DRG 871 (septicemia) are commonly at the top of many lists of those DRGs having the highest financial impacts. A bit lower down the list might be MS-DRGs such as 330 (major small and large bowel procedures) and 603 (cellulitis).

There are several types of ICD-10 testing to be conducted. System testing verifies that individual systems function properly. Interoperability testing determines if systems such as electronic health record (EHR) systems and coding systems work effectively together. End-to-end testing checks the entire workflow. Finally, revenue impact testing tests the results of claims adjudication with cooperating payer partners. Typically, an 837 claim is transmitted in both ICD-9 and ICD-10 format and the resulting 835 remittance advice is analyzed to assess future revenue impact.

Several special methodologies can be used to get the most ICD-10 testing done. A test database of natively coded ICD-9 and ICD-10 records is used to help test workflows. Though many hospital coding departments are able to code test data records, they are probably very busy. Having a testing partner that can provide a large test data repository can expedite testing.

Test automation is also used to get more testing done in the time remaining before implementation. Test automation tools have been developed for most of the most popular health information management (HIM) systems. These tools load test data into the various applications automatically. They enable more testing to be completed in a given period of time. Significantly, test automation tools will be useful for ongoing regression testing after the ICD-10 testing is completed.

Whether you engage one test engineer or a half dozen, there is still much that can be done to mitigate ICD-10 risk in the months ahead. Using a risk-based testing approach will ensure that you test the most important workflows first, and your institution thus will be that much better prepared come Oct. 1.

About the Author

Tom Parnon is the director of business development for QualiTest. He has nearly 30 years of experience in IT sales and marketing. He has been with QualiTest for four years. During this time he has helped assemble teams that have successfully conducted large healthcare testing projects. He has worked in support of Meaningful Use testing, ICD-10 testing, and test automation projects.

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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.

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