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ICD-10 Test Cases

ICD-10 Test Cases

QualiTest has vast ICD-10 testing experience providing end-to-end services to various providers and payers. As part of the work being done across the country, QualiTest has developed a library of ICD-10 test cases and ICD-10 testing scenarios.

Samples of ICD-10 Testing Scenarios and ICD-10 Test Cases:

# High level ICD-10 test case Remarks
1 Inpatient Scheduling, Registration, Insurance Eligibility Check, Prior Authorization, Referrals, Admission, patient care/charting, Orders, discharge, coding, billing/claim submission, claim adjudication, reconciliation
2 Outpatient
3 Preventive and Screening Services
4 ED 
5 ED to Inpatient
6 Surgical
7 Rehab
8 OB: Labor/Delivery
9 Skilled Nursing Facility
10 ESRD facility
11 Hospice Care
12 Longterm care
13 Ambulatory Surgical Centers
14 Workers Comp claims
15 Top 100 DRGs by payer/speciality/Line of Business
16 Top 100 DRG Shifts by payer/speciality/Line of Business
17 Top 200 Diagnosis Codes by payer/speciality/Line of Business
18 Top 200 Procedure Codes by payer/speciality/Line of Business
19 Codes resulting in DRG shifts  
20 Case Mix Index changes  
21 Medicare Plans Part A Health Plan/Payer tyes
22 Medicare Plans Part B  
23 Medicare Plans Part A & B  
24 Medicaid Plans  
25 Blue Cross Blue Shield Plans  
26 Commercial Payers Traditional (PPO)  
27 Commercial Payers plans  Managed Care (HMO)  
28 Inpatient :MS-DRGs Reimbursement Schemes
29 Inpatient :AP-DRGs  
30 Inpatient :APR-DRGs  
31 Inpatient :DRG based Carve outs  
32 Episode Based Reimbursements ex. Bundled payemnt for hip replacements
33 Performance Based Reimbursements  
34 Risk-adjusted Reimbursements ICD-10 based Hierarchical Condition Categories(HCCs) and Pharmacy HCCs (RxHCC) models
35 UCR Usual and Customary Reimbursement
36 IRF-PPS Inpatient Rehabilitation Facility Prospective Payment System 
37 RUG Skilled nursing facility Resource Utilzation Group
38 HHRG Home Health Resource Group
35 Hospital Based Charges  
35 Date of Service before 10/1/2014 Date os Service based test scenarios
36 Date of Service after 10/1/2014  
37 Same episode spanning few days before and few days after 10/1/2014  
38 ICD-9 codes with no ICD-10 mapping Mapping Risks
39 ICD-9 codes with 1:1 apropximate mapping  
40 ICD-9 codes with 1 to many mapping  
41 ICD-9 codes with 1:many combinations (AND)  
42 ICD-9 codes with 1:many  approximate clusters (OR)  
43 ICD-9 codes with 1:many  complex mapping (AND's and OR's)  
44 ICD-9 codes with 1:many  cluster, combination and complex mapping  
45 Dx and Px codes for high audit risk  
46 Dx and Px codes for high denial risk  
47 Dx and Px codes for high PENDed risk