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Qualedix QA and the North Carolina Healthcare Information and Communications Alliance (NCHICA) are piloting a trading partner certification program and an ICD-10 testing framework for end-to-end testing. This pilot represents a shared work effort involving test data creation, dual coding, testing and trading partner coordination, with clinically accurate ICD-10 test data at its core.

This state-of-the-art testing methodology developed by Qualedix QA creates highly reusable test data for all participants and their trading partners so that entities can measure themselves against a common national standard of key billed medical procedures.

Participating pilot hospitals or health systems include Rex Health, the Carolinas Healthcare System, the University of North Carolina at Chapel Hill, Wake Forest Baptist Health and UNC Health Care, and to date more than 100 highly relevant clinical scenarios have been dual-coded and peer-reviewed (with another 100 still in progress).

We have been fortunate that the early-adopter hospitals had great documentation of current records to begin with, meaning the majority of the transactions could be coded in ICD-10 without much rework or disagreement in the coding standards. This dual-coding exercise will continue through the end of September, when we will begin the physical testing effort.

Some of the clinical scenarios under test include:

  • Coronary atherosclerosis
  • Intermediate coronary syndrome
  • Complication due to cardiac device
  • Atherosclerosis
  • Diabetes mellitus
  • Delivery by Cesarean
  • Hyperlipidemia
  • Anemia
  • Sepsis
  • Cerebral embolism
  • Vascular stent
  • Unilateral thyroid lobectomy
  • Spinal fusion
  • Septicemia
  • Pneumonia
  • Lymphoma
  • Lap band
  • Epistaxis

The next step in the test case development process is the sharing of dual-coded clinical scenarios with two participating health plans, United Healthcare and Blue Cross Blue Shield of North Carolina. They will conduct an initial scenario review, a coding review and internal mapping comparisons versus actual ICD-10 coding in medical records. This is a crucial step in the process, as health plans will be able to gain key insights into the types of transactions and code sets they will see in play when ICD-10 goes live.

We anticipate receiving feedback from the health plans throughout the months of September and October, and we will share key insights when they become available. These health plans should be commended for demonstrating forward thinking in getting out in front of ICD-10 testing issues early and often.

Once the coding has been solidified, the transactions and associated file formats will be transferred to encoder products from 3M and Optum for internal testing to ensure that these products find the right codes, which already have been determined in the initial analysis based on the medical records. The transactions also will be sent to AllScripts to cover the clearinghouse side of things, with additional testing to be done in order to ensure that file conversion from vendor software can be done properly and pass 5010 compliance tests in relation to these high-frequency clinical test cases.

The health plans will receive compliant 5010 transactions based on the exact clinical scenarios that were reviewed in order to ensure complete traceability to the original test cases. The health plans also will have the ability to test the transactions internally once their systems have been remediated, allowing them to produce accurate ICD-10-based adjudication and remittances.



The reason this pilot sets the standard for key end-to-end testing methods is that it delivers the ability to show vendors, clearinghouses and health plans what actually will be sent and shared in a live environment – as opposed to basing an entire testing effort on internal payer mappings only. Providers will gain crucial insights into various mapping rules and the contracts they have with each health plan, based on the developed clinical scenarios.

As an industry we must pay close attention to the lessons learned from 5010 testing and avoid testing in a vacuum or just assuming that transactions will be accurate. Visibility by all healthcare stakeholders into every other stakeholder’s readiness level is absolutely critical to ensure that ICD-10 is tested correctly.

Key lessons learned under the purview of the pilot test cases include the following:


  1. Focus on data content to ensure that required 5010 elements are correct. This means using street addresses instead of PO boxes, applying correct NPI numbers, identifying conditional data elements needed when inpatient or outpatient bill types are present, and ensuring that claim lines and service lines represent the correct billed amounts as entered.
  2. Ensure that the provider claims represented in the vendor system carry through to the clearinghouse output of accurate 5010 institutional claims.
  3. Test more than just one element across a few select trading partners; instead, incorporate and involve multiple stakeholders in the testing process in order to achieve greater testing economies of scale.


An added benefit to the industry is this: upon completion of these key medical scenarios and associated testing efforts, the test cases can be shared nationally with all other covered entities      to assist them with their testing efforts, saving costs in test data creation and end-to-end testing activities.

About the Authors

Mark Lott is the CEO of Qualedix QA Services, Inc. Mr. Lott’s 25 year career in software testing and quality assurance expertise in healthcare, pharmaceutical and banking has led to the development of cutting edge testing methodologies and end-to-end testing platform for ICD-10. Mark’s career as a successful entrepreneur and executive includes his role as Chairman of HCCO (Health IT Conformance and Certification Organization) where he architected the first HIPAA interoperability testing methodology called CCAP (Common Conformance Assessment Program) for 4010 and certified the majority of EDI validators and translators in use today.

Christian Omba currently serves as the ICD-10 Program Manager for Rex Healthcare, where he is responsible for the implementation of people, process and technology solutions to meet the ICD-10 regulatory requirements. Christian is a 25-year veteran of Business Operations and Technology management. He has successfully led a variety of industries to meet regulatory compliance, technology optimization, resource optimization, and legal requirements.

Contact the Authors



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