KAISER PERMANENTE
ICD-10 External Provider
Testing Guidelines
4/9/2015
Date
11/15/2013
11/25/2013
1/10/2014
1/17/2014
Version
0.1
0.2
0.3
0.4
1/20/2014
1.0
1/31/2014
2/6/2014
1/20/2015
3/18/15
1.1
1.2
1.3
1.4
KP Review Level
KP ICD-10 ETP Team
KP ICD-10 ETP Team
KP ICD-10 ETP Team
KP ICD-10 Realization Team
Leads
KP ICD-10 Steering Committee
Work Group
Initial External Provider Input
KP ICD-10 ETP Team
KP ICD-10 ETP Team
KP ICD-10 ETP Team
Comments
Initial
Peer Review
Initial stakeholder input incorporated
Document distributed and reviewed by all KP
regions
Revision to 835 ERA references
Expanded upon CMS Level II position
Included mock compliance dates, across regions
Updated per compliance delay to 10/1/2015
Removed reference to OH, references to paper
claims
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ICD-10 External Provider Testing Guidelines
4/9/15
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1.5
KP ICD-10 ETP Team
Changed Mock Compliance dates for NCAL and
SCAL to 5/14/15.
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ICD-10 External Provider Testing Guidelines
Table of Contents
1.
Purpose of ICD-10 External Provider Testing Guidelines...................................................................... 3
2.
Background ........................................................................................................................................... 3
3.
ICD-10 Testing and CMS Compliance.................................................................................................... 3
3.1. What do the CMS Guidelines mean for Kaiser Permanente? ....................................................... 4
4.
External Testing Success Criteria .......................................................................................................... 4
5.
Provider Testing Process and Timelines ............................................................................................... 5
5.1. Defect Resolution/Re-test Process ............................................................................................... 6
6.
Test Plan................................................................................................................................................ 6
6.1. Mock Compliance Date and Data De-identification Strategy ....................................................... 6
6.2. Test Scenarios ............................................................................................................................... 7
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ICD-10 External Provider Testing Guidelines
1. Purpose of ICD-10 External Provider Testing Guidelines
The purpose of the ICD-10 External Provider Testing Guidelines is to provide a consistent set of ICD-10
testing instructions for external providers and associated clearinghouses. It is designed to set
expectations for testing scope, process and standards. The testing process is described, including logging
and triaging issues in addition to establishing successful testing outcome criteria. The testing guidelines
are intended for external providers and clearinghouses only and do not include third party
administrators, rental networks, vendors and government agencies.
The objective of testing with external providers is to demonstrate the ability to send and receive
healthcare transactions, utilizing the ICD-10 code set. Specifically, KP is not to test ICD codes themselves,
but rather the usage of codes based on the claim date of service and according to CMS guidelines.
2. Background
In the January 16, 2009 Federal Register (74 FR 3328), the Department of Health and Human Services
(HHS) published a final rule in which the Secretary of Health and Human Services (HHS) adopted the ICD10-CM and ICD-10-PCS (hereafter referred to as “ICD-10”) code sets as the HIPAA standards to replace
the previously adopted International Classification of Diseases, 9th Revision, Clinical Modification,
Volumes 1 and 2 (diagnoses), and 3 (procedures), including the Official ICD-9-CM Guidelines for Coding
and Reporting. The compliance date set by the final rule was originally October 1, 2013.
In the September 5, 2012 Federal Register (77 FR 172), HHS changed the compliance date for ICD-10
from October 1, 2013 to October 1, 2014. On April 1 2014, President Obama signed the Protecting
Access to Medicare Act of 2014 (H.R. 4302), which in addition to extending current Medicare physician
pay rates, delayed the implementation compliance date to 10/1/2015.
Kaiser Permanente intends to fully comply with the legal requirements put forth by the Centers for
Medicare & Medicaid Services (CMS) in the ICD-10 mandate and we strongly encourage our external
institutional and professional providers to do the same. Beginning October 1, 2015, we will process
claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient)
prior to October 1, 2015. We will continue to monitor CMS' position closely and will adjust our approach
as necessary.
3. ICD-10 Testing and CMS Compliance
Kaiser Permanente (KP) is committed to meeting the ICD-10 mandate put forth by CMS. While KP has
taken the necessary steps to meet the ICD-10 requirements internally; external trading partner testing
will allow KP and its partners to meet CMS compliance guidelines and to manage business risk
associated with the ICD-10 cutover.
CMS has provided a framework for industry-wide ICD-10 testing within the publication of
documentation on the http://www.cms.gov website. CMS Level I is internal to Kaiser Permanente and
will be completed prior to engaging external providers during test effort. KP intends to meet the
objectives of CMS Level II by successfully testing ICD-10 with its external providers.
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Table 1: Excerpt from ICD-10 Implementation Guide for Payers
CMS Level l (Internal Testing) compliance indicates that entities covered by HIPAA can create and
receive compliant transactions.
 Transactions should maintain the integrity of content as they move through systems and
processes
 Transformations, translations, or other changes in data can be tracked and audited
CMS Level II (External Testing) compliance indicates that an entity covered by HIPAA has completed
end-to-end testing with each of its external trading partners and is prepared to move into production
mode with the new versions of the standards by the end of that period.
 Trading-partner testing portals need to be established1
 Transaction specification changes should be defined and communicated2
 Inbound and outbound transaction-related training may be required3
 A certification process may be needed for inbound transactions4
 Rejections and re-submissions related to invalid codes at the transaction level are handled5
 Parallel test systems to test external transactions6
Source: http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD10Payers508.pdf (see page 45)
3.1. What do the CMS Guidelines mean for Kaiser Permanente?
In order to satisfy CMS level I testing guidelines, KP has remediated its EDI gateway and
claims processing system with the capability to receive inbound claims from external
providers that contain ICD-10 codes. KP intends to satisfy CMS Level II testing guidelines by
engaging a representative sample of external providers to submit test claims with ICD-10
codes. And specifically, this is Kaiser’s position on CMS’ six bullet points in Table 1 above:
1
KP is not using any 3rd party portals for ICD-10 testing; rather, KP is using existing
clearinghouse testing processes. Refer to your clearinghouse for test file submission and
receiving instructions.
2
Refer to section 6 of this document for test scenarios.
3
As training needs arise, KP and the external provider will collaborate together as
necessary.
4
KP is using CMS acceptance and rejection criteria for ICD-10. KP is not requiring a
certification process.
5
Refer to section 5.1 for testing transparency statement.
6
KP is utilizing a test environment and expects the provider to do so as well. At no time will
any PHI be used during the testing process.
4. External Testing Success Criteria
Based on CMS’ definitions of ICD-10 compliance and CMS Level II testing guidelines, KP has determined
a specific scope list of healthcare transactions that will be tested as part of the external provider testing
effort. Our specific scope list, once tested successfully, will define our testing success criteria.
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ICD-10 External Provider Testing Guidelines
Specifically:
1. An external provider can send claims (837) using ICD-10 codes.
2. KP can receive claims (837) using ICD-10 codes, while applying the same claims acceptance
policy as CMS.
3. KP can send an acknowledgement of acceptance or rejection (999 and/or 277) in response to an
external provider’s claim that utilizes ICD-10 codes.
4. KP can send an electronic remittance advice (835) upon successful adjudication of an external
provider’s test claim that utilized ICD-10 codes.
a. NOTE: Claims pricing is based upon an external provider’s contract with KP. The pricing
returned via ICD-10 inbound claims testing is not guaranteed to be identical to pricing
received after the ICD-10 cutover as pricing mechanisms, such as DRGs, may change.
5. Provider Testing Process and Timelines
KP’s testing period is predicated upon the completion of the remediation process on KP’s claim systems
to send, receive and effectively process ICD-10 codes.
KP anticipates that conducting ICD-10 testing with external providers is a 2-3 week process. The exact
duration of testing will be confirmed during test planning meetings that will involve KP and the specific
external provider. A high level depiction of our external provider testing process is as follows:
Figure 1: ICD-10 External Provider Testing Timeline
Milestone
Planned Testing
Break/Fix Period
Week 1
M
Tu
W
Week 2
Th
F
M
Tu
W
Week 3
Th
F
M
Tu
W
Th
F
Kick-off ETP
Testing
Planned ICD scheduled testing and defect management
Verify Testing
Connectivity
Confirm Test
Execution
Schedule
Confirm Test
Scenarios
Determine if
Break/Fix
period needed
Confirm Retest
Scenarios
Confirm
Testing
Completion
Break/Fix Period: Re-test mutually agreed upon
scenarios, defect management
Prepare/Configure
Data in Test
Environment
Confirm
Testing
Completion
Specific external provider testing processes will vary by the external provider’s associated
clearinghouses. KP is committed to following the standard ICD-10 testing process, as defined by the
clearinghouse and will not create a separate process.
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5.1. Defect Resolution/Re-test Process
In the event that defects are discovered by an external provider, the clearinghouse or KP,
each entity must be informed of the defect. Additionally, the defects should be logged and
both sides must agree on a decision to re-test in order to enter the break/fix period.
However, prior to entering into break/fix period, the external provider and KP must
determine and agree on which scenarios which will be re-tested. Moreover, both parties
must agree on which cases should be re-tested from a regression test coverage perspective.
6. Test Plan
As a payer, KP will provide specific testing scenarios to external providers. Upon discussion and
agreement on the test scenarios, KP and the external provider, working in conjunction with the
clearinghouse, will define the testing schedule.
Upon confirmation of the test schedule, KP and the external provider will need to agree on the specific
test data requirements necessary to coordinate testing between an external provider’s billing system
and KP’s EDI and claims adjudication system, e.g. agreeing on an ICD-10 compliance simulation date. KP
encourages planning sessions with testing project managers and IT SMEs (KP and provider) to discuss
specific testing timelines, test scenarios, test data, de-identification of data strategy, mock compliance
date alignment and additional provider requirements.
6.1. Mock Compliance Date and Data De-identification Strategy
During the KP and the provider planning sessions, IT SMEs and PMs should be in attendance
to work through and eventually confirm test timelines, test scenarios and test data.
Moreover, the mock compliance date and data de-identification strategy is necessary to
ensure that PHI is not used in test.
Table 2: Mock Compliance Date(s), by Region
Region
Northern California (NCAL)
Southern California (SCAL)
Colorado (CO)
Mid-Atlantic States (MAS)
Northwest (NW)
Georgia (GA)
Hawaii (HI)
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Mock Compliance Date
5/14/15
5/14/15
5/28/15
5/28/15
5/28/15
5/28/15
5/28/15
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ICD-10 External Provider Testing Guidelines
6.2. Test Scenarios
As external providers prepare test claims for submission to Kaiser Permanente, KP will
expect between 10 to 25 claims that are representative of the following test scenarios. The
scenarios captured in the table below do not represent the final list of test scenarios. KP
encourages discussions pertaining to additional test scenarios that meet additional provider
requirements, beyond the list in table.
Table 3: ICD-10 Test Scenario Guidelines
#
Test Scenario Guidelines
Type
Expected
Outcome
Notes
ICD-10 Usage For Dates of Service Equal to or Later Than ICD-10 Compliance Simulation Date
1
ICD-10 codes after compliance date
837 I/P
Accept Claim
 May include limited paper claims
 Acknowledgement of receipt and pricing
returned (835)
ICD-10 Usage For Dates of Service Prior to the ICD-10 Compliance Simulation Date
2
ICD-10 codes prior to compliance date
837 I/P
Reject Claim
 May include limited paper claims
 Rejection only, no pricing returned
ICD-9 Usage For Dates of Service Equal to or Later Than ICD-10 Compliance Simulation Date
3
ICD-9 codes after compliance date
837 I/P
Reject Claim
 May include limited paper claims
 Rejection only, no pricing returned
ICD-9 Usage For Dates of Service Prior to the ICD-10 Compliance Simulation Date
4
ICD-9 codes prior to compliance date
837 I/P
Accept Claim
837 I/P
Return to
Provider
 May include limited paper claims
 Acknowledgement of receipt and pricing
returned (835)
ICD-9 and ICD-10 Code Combinations on the Same Claim
5
Claims that contain both ICD-9 and ICD-10 codes
 KP or Clearinghouse to reject claim as
unprocessable
Claims that Span the ICD-10 Compliance Simulation Date
6
Refer to CMS guidelines in the table below – source (see Figure 2)
Appropriate Usage of ICD Code Set Indicator
7
8
Diagnosis code indicator “BK” for ICD-9 or “ABK” for
ICD-10
Procedure code indicator “BR” or “BQ” for ICD-9, or
“BBR” or “BBQ” for ICD-10
Appropriate code set indicator usage is required for both testing and
production operations
Table 4: Institutional Providers (MM7492)
#
Bill
Types
Facility Types/Services
Institutional Providers
1
11X
Inpatient Hospitals (incl. TERFHA
hospitals, Prospective Payment
System (PPS) hospitals, Long Term
Care Hospitals (LTCHs), Critical
Access Hospitals (CAHs)
2
12X
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Inpatient Part B Hospital Services
Claims Processing Requirement
Use FROM or
THROUGH
Date
If the hospital claim has a discharge and/or through date on or
after 10/1/15, then the entire claim is billed using ICD-10.
THROUGH
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
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ICD-10 External Provider Testing Guidelines
#
Bill
Types
3
13X
Outpatient Hospital
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
4
14X
Non-patient Laboratory Services
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
5
18X
Swing Beds
If the [Swing bed or SNF] claim has a discharge and/or through
date on or after 10/1/15, then the entire claim is billed using ICD10.
THROUGH
6
21X
Skilled Nursing (Inpatient Part A)
If the [Swing bed or SNF] claim has a discharge and/or through
date on or after 10/1/15, then the entire claim is billed using ICD10.
THROUGH
7
22X
Skilled Nursing Facilities (Inpatient
Part B)
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
8
23X
Skilled Nursing Facilities
(Outpatient)
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
9
32X
Home Health (Inpatient Part B)
Allow HHAs to use the payment group code derived from ICD-9
codes on claims which span 10/1/2015, but require those claims
to be submitted using ICD-10 code.
THROUGH
10
3X2
Home Health – Request for
Anticipated Payment (RAPs)*
* NOTE - RAPs can report either an ICD-9 code or an ICD-10 code
based on the one (1) date reported. Since these dates will be
equal to each other, there is no requirement needed. The
corresponding final claim, however, will need to use an ICD-10
code if the HH episode spans beyond 10/1/2015.
*See Note
11
34X
Home Health – (Outpatient )
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
12
71X
Rural Health Clinics
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
13
72X
End Stage Renal Disease (ESRD)
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
14
73X
Federally Qualified Health Clinics
(prior to 4/1/10)
N/A – Always ICD-9 code set.
15
74X
Outpatient Therapy
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
16
75X
Comprehensive Outpatient Rehab
facilities
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
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Facility Types/Services
Claims Processing Requirement
Confidential and Proprietary to Kaiser
Use FROM or
THROUGH
Date
FROM
FROM
N/A
ICD-10 External Provider Testing Guidelines
#
Bill
Types
Facility Types/Services
Claims Processing Requirement
Use FROM or
THROUGH
Date
FROM
17
76X
Community Mental Health Clinics
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
18
77X
Federally Qualified Health Clinics
(effective 4/4/10)
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
19
81X
Hospice- Hospital
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
20
82X
Hospice – Non hospital
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
FROM
21
83X
Hospice – Hospital Based
N/A
22
85X
Critical Access Hospital
Split Claims - Require providers split the claim so all ICD-9 codes
remain on one claim with Dates of Service (DOS) through
9/30/2015 and all ICD-10 codes placed on the other claim with
DOS beginning 10/1/2015 and later.
N/A
FROM
Table 5: Special Outpatient Claims Processing Circumstances (MM7492)
Scenario
Claims Processing Requirement
Use FROM or
THROUGH
Date
Special Outpatient Claims Processing Circumstances
3-day /1-day
Payment Window
Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient
bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on
or after 10/1/2015, the claim must be billed with ICD-10 for those bundled outpatient services.
THROUGH
Table 6: Professional Claims (MM7492)
Type of Claim
Claims Processing Requirement
Use FROM or
THROUGH
Date
Professional Claims
All anesthesia claims
Anesthesia procedures that begin on 9/30/15 but end on 10/1/15 are to be billed with ICD-9
diagnosis codes and use 9/30/15 as both the FROM and THROUGH date.
FROM
Table 7: Supplier Claims (MM7492)
Supplier Type
Claims Processing Requirement
Use FROM or
THROUGH
Date
Supplier Claims
DMEPOS
Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient
bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on
or after 10/1/2015, the claim must be billed with ICD-10 for those bundled outpatient services.
FROM
Tables 4, 5, 6 and 7 may be found on the Center of Medicare and Medicaid Services (CMS) website:
http://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnmattersarticles/downloads/SE1408.pdf
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MM7492, however, did not include 33X as a bill type for the requirements provided. MM7704 adds
the requirements for bill type 33X:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7704.pdf
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