While supplies last! Free 2022 Essentials of Interventional Radiology Coding book with every ICD10monitor webcast order. No code required. Order now >

The gravity of undertaking a complete replacement of one of the most essential elements of the healthcare reimbursement mechanism cannot be overstated: If ICD-10-CM implementation is executed flawlessly, there will be little difference between “before” and “after,” yet if there are problems, the impact will range from painful to cataclysmic.

As someone said recently, “There is no greater disruption to healthcare than changing the payment model.” Changing the way we code medical claims and the associated processing and adjudication of medical claims is tantamount to changing the payment model entirely. We must learn from the mistakes made in transitioning from 4010 to 5010, and undertake the transition from ICD-9-CM to ICD-10-CM in a way that demonstrates that learning.

In our view, central among the shortcomings in the 5010 transition was the lack of a standard definition of what it meant to be “5010-ready.” What we subsequently learned was that every entity in the claims processing chain had a different definition of the term “ready.” We believe it is not possible to be truly “ready” until meaningful end-to-end testing has been done.

We also learned from the 5010 conversion that payer testing has been severely limited. The first six months of 2012 underscored this point in that many payers only tested syntax prior to the implementation of 5010, and in many cases the scope of testing did not cover true edits adequately – nor did these efforts involve end-to-end testing with full claim level adjudication and remittances.

As we all know, ICD-10 will have far more impact and will involve far more change than 5010. Unlike 5010, physicians must be personally and actively involved in the ICD-10 process. We are concerned that, unless the lessons learned from 5010 materially inform and affect the implementation of ICD-10 CM, the economic stability of America’s healthcare reimbursement systems will be at risk and could be severely compromised.

We cannot stress enough that, in relative terms, adoption and implementation of 5010 was simple compared to ICD-10 CM.

Every vendor system that stores, uses, depends on, transmits or receives an ICD code, for whatever purpose, must have some degree of modification made to some component of its software to accommodate ICD-10 CM. In the process, each vendor will be forced to make decisions and set rule(s) or policies regarding how it will treat ICD-10 CM codes and handle the transition to the new coding set. While some elements of the modifications necessary to prepare for ICD-10 CM have been addressed by many vendors, payors and clearinghouses during the transition from ANSI 4010A1 to ANSI X12 5010A1, an enormous amount of work remains.

If data cannot get to its intended location in the proper form and be received and interpreted in the proper form, then submission of claims (and certainly “clean” claims and the proper payment of claims) can be interrupted.  Innumerable interfaces exist because there are various approaches the owners of each type of system can take when setting policies for handling data interchanges involving ICD codes. Some owners may choose to use the GEMs mapping system, proprietary translation tools, or other methodologies.  Others may choose to extend maintenance and support of both ICD-9-CM and ICD-9-CM tables well beyond the final implementation date for ICD-10 CM. In fact, HIPAA-exempt insurers, such as automobile, tort and workers’ compensation plans, may continue to utilize ICD-9-CM for years to come.

Because there are at least two entities involved in each interface, there must be ample time allowed for communication and necessary development/modification for every data trading instance to handle the specifics.  Building these communication and translation systems will be very time- and resource-consuming activities, and failure to execute them properly could create chaos in the healthcare world. Providers and billers could be rendered incapable of functioning if these systems are not considered and sufficient time is not provided for their development when the time frame for ICD-10 CM is finalized.

While the transport aspects of ICD-10-CM processing for the most part have been covered, many if not all electronic data interchange/clearinghouse vendors will need adequate time to incorporate updates to their data validation or edit systems. This includes code validation, date validation, medical necessity validation, correct coding initiatives and all published and promulgated payer rules based on diagnosis and procedure coding.

One of the lessons learned during the 5010 conversion was that adequate notification of coding edits will be necessary to ensure successful testing between feeder systems (PMS and HIS) and the electronic data interchange/clearinghouse systems, as well as any testing between payers and providers.

We know CMS heard this message and has established a work group of collaborating industry partners tasked to establish benchmarks that cannot be ignored in order to assess the status of “ready” and “end-to-end” testing for the healthcare industry.



Finally, it is likely that some payer systems will not be able to process true ICD-10-CM codes at the point when ICD-10 goes into effect. Some payors have acknowledged that they will use crosswalks to convert ICD-10-CM codes to ICD-9-CM for adjudication purposes, and that some type of conversion will take place when providing electronic remittance transactions to the providers.  This will result in providers needing information to determine if payments are being issued in accordance with contracted agreements between providers and payers.

Recommendation One:

CMS should adopt and enforce a uniform definition of being ICD-10-CM-ready.

As you know, some vendors and health plans already have announced that they are ICD-10-CM-ready. Clearly, however, this cannot be true, as there has been no external end-to-end testing or payment impact analysis for claims performed (other than the CMS-3M project for DRG-to-ICD-10 comparison). Because there is currently no true definition of “ready,” plans and vendors can make such assertions without consequence.

Being “ICD-10-CM-ready” should mean, at a minimum, that complete end-to-end testing of 837 and 835 transactions in full production has been accomplished. Any maps or crosswalks used by a health plan to adjudicate a 5010/ICD-10-CM-compliant claim should be made publicly available and the diagnosis code(s) used for claims adjudication reported.

HBMA recommends that health plan coverage policies be published by Oct. 1, 2013. This would allow adequate time for education, training, programming, data analysis and incorporation into end-to-end testing.

HBMA also recommends that the definition of “ready” encompass work involving all of the transaction types, not just the ability to submit claims or process remittances containing ICD-10-CM codes.

Recommendation Two:

HBMA recommends that CMS identify and publish specific, verified readiness milestones for providers and insurers.

In addition, as we have recommended in the past, HBMA strongly recommends that implementation milestones be tiered as follows:

  1. One milestone date for data interchanges between systems used by entities other than payors.
  2. One milestone date for completion of testing with all payers
  3. One milestone date for production with all payers

A full year of true end-to-end testing should be available, with clear dates set for when payers must have a testing schedule established. In addition, the testing should provide for a full week’s worth of de-identified production claims processed in a test harness. This will ensure that all possible test scenarios are taken into account.

Failure to require all payers, providers and vendors to adhere to established timelines, testing schedules, complete and thorough end-to-end testing, transparency in transactions, and widely accepted definitions could result in insurmountable problems.

Because ICD-10-CM is the foundation for multiple other CMS initiatives, successful transition and implementation of ICD-10-CM has broad implications.


Coordinated industry collaboration and cooperation is necessary for success. The definitions of “ready” and “end-to-end” testing must be agreed upon, relied upon and used as the criteria for objective evaluation of the ability to implement ICD-10 successfully.

About the Author

Holly is a member of the Healthcare Billing and Management Association (HBMA) and chairs the ICD-10 Committee.  The committee developed definitions for readiness and end-to-end testing for successful ICD-10 implementation.

Contact the Author


To comment on this article please go to editor@icd10monitor.com

EDITOR’S NOTE: Register to listen today’s Talk Ten Tuesday (10 AM ET) when Kari Gaare from CMS and Dean Cook from NGS discuss the CMS pilot for end-to-end testing.


You May Also Like

Medlearn Media NPOS Non-patient outcome spending

The PHE Update

The renewal of the PHE indicates that a public health emergency (PHE) exists. As expected, the COVID-19 PHE (Public Health Emergency) was extended for the

Read More

Leave a Reply

Your Name(Required)
Your Email(Required)