Updated on: November 21, 2016

The Consistency of Inconsistency: ICD-10 Testing Requirements Vary with Payers

By Betty Lengyel-Gomez
Original story posted on: July 13, 2015

Cooperative Exchange (CE), the National Clearinghouse Association recently surveyed its members regarding its recent ICD-10 testing experiences. The CE received informative and helpful feedback on members testing with different types of payers: Medicare; Medicaid; commercial health plans; Tricare; Property and Casualty (P&C); and group health payers.

As you can imagine, each clearinghouse’s experience varied depending on the payers they engaged. First, all of the payers have very different requirements. Some of the payers require specifics of the Insured ID and specific date of service (DOS). Some will return the 835 but will not answer any questions if there are differences. Others have engaged in conversations to discuss differences between the ICD9 835 and the ICD10 835. Some payers have been testing with clearinghouses since 2013. But most payers have only been testing for the last couple of months or are just starting in July.

Through this testing engagement, Cooperative Exchange members came to realize that there isn’t any true "end-to-end" testing being done. For P&C payers, the states dictate the payer ICD-10 requirements. To date, 22 states have declared ICD-10 adoption. The states that have declared ICD-10 readiness adopted the the Centers for Medicare & Medicaid Services  (CMS) ICD-10 guidelines. However, in regards to end-to-end testing even with the states, there has been limited testing reflecting similar experiences realized by the rest of the healthcare industry.

Clearinghouses have seen an increase in payers willing to do ICD-10 end-to-end testing in the past month. We expect to see this trend increase due to system validation processes completed and moving to the next stage of financial validation testing results. The percentage of errors we are seeing from a clearinghouse perspective is extremely low due to ICD front-end edit applications. There have also been good success rates on the transactions that returned an 835. Unfortunately, most of the payers are unable to send back an 835 or a 999. The results are not very definitive, and most are just acknowledging they have received the file.

End-to-end testing results have been all over the board. CE members identified several issues for the payers and they have all been very appreciative of that input. It does take hours of time to get payers to figure out the errors but it ensures positive results when they do. When the claims are coded and processed correctly, we have found that the differences from the ICD-9 835 to the ICD-10 835 have been the same almost to the penny in most situations.

With Round 1 and Round 2 of CMS Testing, our members found that different intermediaries processed the “TEST” claims sent to the TEST System with a “T” indicator as Live. Duplicate denials came back as LIVE. Also, validating patient eligibility during testing caused a lot of unnecessary rejections and repeat work.

The CE offers up the following recommendations regarding (future) testing:

  • There is a need for more diverse end-to-end testing to get a better representation of the small provider and specialties.
  • Payers should target their high-volume and high-dollar providers for end-to-end testing, including their specialty providers. This has been a well-published guideline; however, some payers are still not applying these principles.
  • Payers should publish their test results with the industry.
  • Everyone should continue to prepare for the switch to ICD-10, which means utilizing the code sets and being prepared financially for the possible delay in payments and other transitional hardships that could come up.
  • If you have not engaged in end-to-end testing, you need to get started now.  End-to-end testing will provide you with a snapshot of potential issues you may have post-October 1, 2015. This information will help you with being proactive in your contingency planning and provide you with the opportunity to mitigate future issues.
  • Remember that payers are still performing end-to-end testing on limited bases.
  • Quickly obtain information regarding your most critical payers’ testing capabilities. Access the CE Payer testing Directory at: http://www.cooperativeexchange.org/6,icd-10-payer-testing-directory.html
  • To the payers: The testing should have been more standardized. If the payer wanted information padded in the test files, they should have done that on their side and not required the providers to.  
  • All payers should have made their test sites capable of accepting the ICD-10 codes with the current dates of service on the claim rather than making the provider change every line item to a date between October 1, 2015, and December 31, 2015.
  • Providers: Check with your software vendors if there is a way for them to create test claims that can meet the payer requirements for testing. They may not want to test with all payers, but if they test with your top five payers that would help you understand if you and the payers are ready and what effect the outcome will have on your revenue, if any.

Finally, make sure you take advantage of CMS’ last testing wave and take any possible opportunity to test with your clearinghouse and your top payers.

About the Author

Betty Gomez is the Cooperative Exchange ICD-10 liaison and the compliance manager/director of Government Healthcare Solutions for Xerox Healthcare, LLC.

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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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