[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]






                    EXAMINING ICD-10 IMPLEMENTATION

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                           FEBRUARY 11, 2015

                               __________

                            Serial No. 114-9


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]




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                    COMMITTEE ON ENERGY AND COMMERCE

                          FRED UPTON, Michigan
                                 Chairman

JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Chairman Emeritus                    Ranking Member
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
JOSEPH R. PITTS, Pennsylvania        ELIOT L. ENGEL, New York
GREG WALDEN, Oregon                  GENE GREEN, Texas
TIM MURPHY, Pennsylvania             DIANA DeGETTE, Colorado
MICHAEL C. BURGESS, Texas            LOIS CAPPS, California
MARSHA BLACKBURN, Tennessee          MICHAEL F. DOYLE, Pennsylvania
  Vice Chairman                      JANICE D. SCHAKOWSKY, Illinois
STEVE SCALISE, Louisiana             G.K. BUTTERFIELD, North Carolina
ROBERT E. LATTA, Ohio                DORIS O. MATSUI, California
CATHY McMORRIS RODGERS, Washington   KATHY CASTOR, Florida
GREGG HARPER, Mississippi            JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            JERRY McNERNEY, California
BRETT GUTHRIE, Kentucky              PETER WELCH, Vermont
PETE OLSON, Texas                    BEN RAY LUJAN, New Mexico
DAVID B. McKINLEY, West Virginia     PAUL TONKO, New York
MIKE POMPEO, Kansas                  JOHN A. YARMUTH, Kentucky
ADAM KINZINGER, Illinois             YVETTE D. CLARKE, New York
H. MORGAN GRIFFITH, Virginia         DAVID LOEBSACK, Iowa
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILL JOHNSON, Ohio                   JOSEPH P. KENNEDY, III, 
BILLY LONG, Missouri                 Massachusetts
RENEE L. ELLMERS, North Carolina     TONY CARDENAS, California
LARRY BUCSHON, Indiana
BILL FLORES, Texas
SUSAN W. BROOKS, Indiana
MARKWAYNE MULLIN, Oklahoma
RICHARD HUDSON, North Carolina
CHRIS COLLINS, New York
KEVIN CRAMER, North Dakota

                                 _____

                         Subcommittee on Health

                     JOSEPH R. PITTS, Pennsylvania
                                 Chairman
BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
  Vice Chairman                        Ranking Member
ED WHITFIELD, Kentucky               ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois               LOIS CAPPS, California
TIM MURPHY, Pennsylvania             JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            G.K. BUTTERFIELD, North Carolina
MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
LEONARD LANCE, New Jersey            DORIS O. MATSUI, California
H. MORGAN GRIFFITH, Virginia         BEN RAY LUJAN, New Mexico
GUS M. BILIRAKIS, Florida            KURT SCHRADER, Oregon
BILLY LONG, Missouri                 JOSEPH P. KENNEDY, III, 
RENEE L. ELLMERS, North Carolina         Massachusetts
LARRY BUCSHON, Indiana               TONY CARDENAS, California
SUSAN W. BROOKS, Indiana             FRANK PALLONE, Jr., New Jersey (ex 
CHRIS COLLINS, New York                  officio)
JOE BARTON, Texas
FRED UPTON, Michigan (ex officio)



















                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     2
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     2
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     3
Hon. Fred Upton, a Representative in Congress from the State of 
  Michigan, prepared statement...................................   110

                               Witnesses

Edward Burke, M.D., Beyer Medical Group..........................     5
    Prepared statement...........................................     8
    Answers to submitted questions...............................   146
Richard F. Averill, Director of Public Policy, 3M Health 
  Information Systems............................................    12
    Prepared statement...........................................    14
    Answers to submitted questions...............................   150
Sue Bowman, Senior Director, Coding Policy and Compliance, 
  American Health Information Management Association.............    19
    Prepared statement...........................................    21
    Additional material for the record...........................    34
Kristi A. Matus, Chief Financial and Administrative Officer, 
  Athena Health..................................................    43
    Prepared statement...........................................    45
    Answers to submitted questions...............................   158
Carmella Bocchino, Executive Vice President, Clinical Affairs and 
  Strategic Planning, America's Health Insurance Plans...........    52
    Prepared statement...........................................    54
    Answers to submitted questions...............................   162
William Jefferson Terry, Sr., M.D., Legislative Affairs Committee 
  Member, American Urological Association........................    63
    Prepared statement...........................................    65
    Additional material for the record \1\
John S. Hughes, M.D., Professor of Medicine, Yale School of 
  Medicine.......................................................    77
    Prepared statement...........................................    79

                           Submitted Material

Report of the Government Accountability Office to the Senate 
  Committee on Finance, ``International Classification of 
  Diseases: CMS's Efforts to Prepare for the New Version of the 
  Disease and Procedure Codes,'' January 2015, \2\ submitted by 
  Mr. Guthrie....................................................    89
Statement of the American Hospital Association, February 11, 
  2015, submitted by Mr. Pitts...................................   111
Letter of February 11, 2015, from The Coalition for ICD-10 to Mr. 
  Pitts and Mr. Green, submitted by Mr. Pitts....................   116
Statement of the Premier Healthcare Alliance, February 11, 2015, 
  submitted by Mr. Pitts.........................................   119

----------
\1\ Additional material submitted by Dr. Terry has been retained in 
committee files and also is available at  http://docs.house.gov/
meetings/IF/IF14/20150211/102940/HHRG-114-IF14-Wstate-TerryW-20150211-
SD001.pdf.
\2\ The report has been retained in committee files and also is 
available at  http://docs.house.gov/meetings/IF/IF14/20150211/102940/
HHRG-114-IF14-20150211-SD006.pdf.
Statement of the American Medical Association, February 11, 2015, 
  submitted by Mr. Pitts.........................................   122
Statement of the American Academy of Dermatology Association, 
  February 11, 2015, submitted by Mr. Pitts......................   129
Statement of Dr. Fred Azar, President, American Association of 
  Orthopaedic Surgeons, February 11, 2015, submitted by Mr. Pitts   131
Statement of Chris Powell, Chief Executive Officer, Precyse, 
  February 11, 2015, submitted by Mr. Pitts......................   136
Article of February 2015, ``Survey of ICD-10 Implementation Costs 
  in Small Physician Offices,'' by Karen Blanchette, et al., 
  Journal of AHIMA, submitted by Mr. Green.......................   141
Letter, undated, from Daniel D. Chamber, Executive Director, Key-
  Whitman Eye Center, to Hon. Pete Sessions, Chairman, House 
  Committee on Rules, submitted by Mr. Burgess...................   143
Letter of February 4, 2015, from C. Duane Dauner, President and 
  CEO, California Hospital Association, to Mr. Cardenas, 
  submitted by Mr. Cardenas......................................   145

 
                    EXAMINING ICD-10 IMPLEMENTATION

                              ----------                              


                      WEDNESDAY, FEBRUARY 11, 2015

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:16 a.m., in 
room 2322 of the Rayburn House Office Building, Hon. Joseph R. 
Pitts (chairman of the subcommittee) presiding.
    Members present: Representatives Pitts, Guthrie, Barton, 
Whitfield, Shimkus, Burgess, McMorris Rodgers, Lance, Griffith, 
Bilirakis, Long, Ellmers, Bucshon, Brooks, Collins, Green, 
Butterfield, Castor, Sarbanes, Schrader, Kennedy, Cardenas, and 
Pallone (ex officio).
    Staff present: Clay Alspach, Chief Counsel, Health; Gary 
Andres, Staff Director; Leighton Brown, Press Assistant; Jerry 
Couri, Senior Environmental Policy Advisor; Andy Duberstein, 
Deputy Press Secretary; Robert Horne, Professional Staff 
Member, Health; Chris Sarley, Policy Coordinator, Environment 
and the Economy; Adrianna Simonelli, Legislative Clerk; Heidi 
Stirrup, Policy Coordinator, Health; Traci Vitek, Detailee, 
Health; Ziky Ababiya, Democratic Policy Analyst; Jeff Carroll, 
Democratic Staff Director; Tiffany Guarascio, Democratic Staff 
Director and Chief Health Advisor; Ashley Jones, Democratic 
Director, Outreach and Member Services; and Arielle Woronoff, 
Democratic Health Counsel.
    Mr. Pitts. The subcommittee will come to order. The Chair 
will recognize himself for an opening statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    The United States currently operates under the 
International Classification of Diseases, 9th Revision (ICD-9) 
code set, which has about 13,000 diagnostic codes. The 
Department of Health and Human Services (HHS) had set a 
mandatory deadline of October 1, 2013, for providers to switch 
from ICD-9 to the greatly expanded ICD, 10th Revision (ICD-10) 
code set, which has 68,000 diagnostic codes and 87,000 
procedural codes.
    Section 212 of H.R. 4302, the Protecting Access to Medicare 
Act, signed into law by President Barack Obama on April 1, 
2014, delayed the transition to ICD-10 until October 1, 2015. 
Many providers and payers, including the Centers for Medicare 
and Medicaid Services, have already made considerable 
investments in the ICD-10 transition, and any further delay 
will entail additional costs to keep ICD-9 systems current, to 
retrain employees, and to prepare, again, for the transition.
    The United States currently lags behind most of the rest of 
the world, which already uses the updated ICD-10. ICD-9 is more 
than 30 years old and does not capture the data needed to track 
changes in modern medical practice and healthcare delivery.
    I would like to welcome all of our witnesses today. We look 
forward to your testimony on this important subject.
    [The prepared statement of Mr. Pitts follows:]

               Prepared statement of Hon. Joseph R. Pitts

    The subcommittee will come to order.
    The Chair will recognize himself for an opening statement.
    The United States currently operates under the 
International Classification of Diseases, 9th Revision (ICD-9) 
code set, which has about 13,000 diagnostic codes.
    The Department of Health and Human Services (HHS) had set a 
mandatory deadline of October 1, 2013 for providers to switch 
from ICD-9 to the greatly expanded ICD, 10th Revision (ICD-10) 
code set, which has 68,000 diagnostic codes and 87,000 
procedural codes.
    Section 212 of H.R. 4302, the Protecting Access to Medicare 
Act, signed into law by President Barack Obama on April 1, 
2014, delayed the transition to ICD-10 until October 1, 2015.
    Many providers and payers, including the Centers for 
Medicare and Medicaid Services, have already made considerable 
investments in the ICD-10 transition, and any further delay 
will entail additional costs to keep ICD-9 systems current, to 
re-train employees, and to prepare, again, for the transition.
    The United States currently lags behind most of the rest of 
the world, which already uses the updated ICD-10.
    ICD-9 is more than 30 years old and does not capture the 
data needed to track changes in modern medical practice and 
healthcare delivery.
    I would like to welcome all of our witnesses today. We look 
forward to your testimony on this important subject.

    Mr. Pitts. With that, I will yield back and recognize the 
ranking member of the subcommittee, Mr. Green, for 5 minutes.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, and good morning and 
thank you to all our witnesses for being here today.
    As we know, ICD-9 was adopted in the United States nearly 
40 years ago. Congress included a requirement that providers 
transition to ICD-10 in the Health Insurance Portability Act of 
1996. Since then, transition has been delayed twice to give 
covered entities time to prepare. ICD-10 transition is 
currently set to take place on October 1, 2015. It is time to 
move forward without further delay.
    ICD-9 was developed in 1979 and there has been significant 
medical breakthroughs which ICD-9 doesn't have codes. ICD-10 
will include the more accurate medical descriptions and account 
for varying symptoms and levels of security. More precise and 
appropriate codes have a number of benefits to our healthcare 
system. Precise information will improve claims processing. 
Insurers will reject fewer claims and not have to ask to 
provide more information as often as they currently do. The 
improved specificity of ICD-10 will help researchers. It will 
allow public health officials to better track disease and 
outbreaks.
    The Affordable Care Act included provisions to move our 
healthcare system from one that rewards value instead of just 
volume. There is still a lot of work to do to improve our 
system in this regard, and adopting ICD-10 without delay would 
help move this forward.
    Providers are increasingly evaluated and held accountable 
based on patient outcomes so more accurate codes can help 
providers improve their patient safety efforts.
    RAND estimated that the cost of transitioning would be 
between $475 million and $1.5 billion over 10 years but that 
the benefits of the system would be between $700 million and 
$7.7 billion in cost savings. According to their analysis, this 
is due to more accurate payments, improved disease management, 
less rejected claims and fewer fraudulent claims. The 
transition to ICD-10 is supported by a majority of the 
healthcare community, a broad-based coalition including 
hospitals, health plans, medical device manufacturers, and the 
health information community opposes any further delay. Each 
has invested substantial time and resources, and further delay 
will be costly and wasteful.
    I understand the medical community has had mixed reactions 
to the transition. Many have invested time and resources to be 
ready for October 1st yet some tell us they are not ready. The 
Centers for Medicare and Medicaid Services says it is ready for 
the transition. CMS has a technical assistance Web site that 
features resources to help providers and others with the 
transition to ICD-10. It has engaged in targeted outreach to 
facilitate the switch. Between CMS and the Coalition for ICD-
10, the resources available to help the transition are 
significant. Many of these are available online for free.
    Each delay has been costly to the healthcare system, and 
ICD transition is an important part of bringing our healthcare 
system into the 21st century, and I yield back my time. Wait a 
second. Does anyone want my time on our side? I yield back my 
time, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman, and now 
recognizes Dr. Burgess, 5 minutes for an opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman. I appreciate the 
recognition. I appreciate our witnesses being here and spending 
time with us this morning at this hearing. I am certainly glad 
we are having the hearing. It is something that I have been 
asking for for some time. I am very glad we are here today 
talking about our readiness and preparedness and have not 
delayed that until September.
    While the transition has been delayed several times by 
various mechanisms, the last-minute delays do nothing to 
relieve the pressure for the small practice that struggles 
under this administrative burden. It does put the health 
systems and the insurers in a difficult position as well. In 
fact, it punishes those who have done exactly what Congress has 
requested.
    So we do need to hear from our witnesses. Are we doing this 
or not? If we are, then the big question for you and me 
becomes, will we be ready?
    Now, I understand that most of the claims processing will 
be done by Medicare contractors and insurance companies. I 
actually have a great deal of faith in their ability to move 
data. That is what they do. But all roads eventually lead to 
the Centers for Medicare and Medicaid Services, and if you will 
pardon me, that does appear to be a weak link in the chain, 
because from healthcare.gov to the Sunshine Act reporting Web 
site, when CMS flips a switch, something breaks, and it is 
invariable, and it has happened time and again. Any time they 
flip a switch and it involves the processing of data, their 
systems fail.
    So it begs the question: Is flipping a switch on October 
1st the right move? If it is, then what is the contingency plan 
for any problems that may develop? Now, contingency plan is a 
phrase I use advisedly because it has been in this subcommittee 
and in the Oversight Subcommittee time and again. With the 
lead-up to healthcare.gov, I asked Gary Cohen, I asked 
Secretary Sebelius, what are the contingency plans if all does 
not go well when you turn this thing on, and I was told no 
contingency plan necessary, we will be ready October 1st. That 
was October 1st, 2013. We know what happened after that.
    So forgive me if I keep repeating the point that I have 
asked for contingency plans in the past, I have been told they 
are not necessary, that everything is fine, until it isn't, and 
then we all scramble. In this case, it could mean disruptions 
in patient care and the ability of small practices to actually 
meet their fiscal obligations that they are required to meet to 
stay in business.
    So today I am anxious to discuss not just the plan ahead 
for the implementation but I would also like to talk about the 
contingencies if everything doesn't go exactly as planned.
    Thank you, Mr. Chairman, for the recognition. I will yield 
back the time.
    Mr. Pitts. The Chair thanks the gentleman. That concludes 
the opening statements. As usual, all members' written opening 
statements will be made a part of the record.
    I would like to ask unanimous consent to submit seven 
documents for the record: a statement on ICD-10 from the 
American Hospital Association; a letter of support from the 
ICD-10 Coalition; a statement from the Premier Healthcare 
Alliance on ICD-10; comments from the American Medical 
Association; comments from the American Academy of Dermatology 
Association; statement from the American Academy of Orthopedic 
Surgeons; and a statement from Precyse, a leader in performance 
management and technology focused on health information 
management. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. We have one panel before us today. I will 
introduce them at this time in the order that they speak: Dr. 
Edward Burke from the Beyer Medical Group; Mr. Rich Averill, 
Director of Public Policy at 3M Health Information Systems; Ms. 
Sue Bowman, Senior Director for Coding Policy and Compliance at 
American Health Information Management Association; Ms. Kristi 
Matus, Chief Financial and Administrative Officer at Athena 
Health; Ms. Carmella Bocchino, Executive Vice President, 
Clinical Affairs and Strategic Planning at America's Health 
Insurance Plans; Dr. William Jefferson Terry, a Member of the 
American Urological Association, a Physician at Urology and 
Oncology Specialists; and Dr. John Hughes, Professor of 
Medicine at Yale University.
    Thank you all for coming. Your written statements will be 
made a part of the record. You will each be given 5 minutes to 
summarize your testimony, and we will start with you, Dr. 
Burke. You are recognized, 5 minutes for your summary.

STATEMENTS OF EDWARD BURKE, M.D., BEYER MEDICAL GROUP; RICHARD 
 F. AVERILL, DIRECTOR OF PUBLIC POLICY, 3M HEALTH INFORMATION 
    SYSTEMS; SUE BOWMAN, SENIOR DIRECTOR, CODING POLICY AND 
COMPLIANCE, AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION; 
 KRISTI A. MATUS, CHIEF FINANCIAL AND ADMINISTRATIVE OFFICER, 
  ATHENA HEALTH; CARMELLA BOCCHINO, EXECUTIVE VICE PRESIDENT, 
   CLINICAL AFFAIRS AND STRATEGIC PLANNING, AMERICA'S HEALTH 
     INSURANCE PLANS; WILLIAM JEFFERSON TERRY, SR., M.D., 
   LEGISLATIVE AFFAIRS COMMITTEE MEMBER, AMERICAN UROLOGICAL 
 ASSOCIATION; AND JOHN S. HUGHES, M.D., PROFESSOR OF MEDICINE, 
                    YALE SCHOOL OF MEDICINE

                   STATEMENT OF EDWARD BURKE

    Mr. Burke. Good morning, and thank you for the opportunity 
to share our journey into ICD-10. My name is Dr. Edward Burke. 
I practice internal medicine in a small, rural community in 
Missouri with a population of about 4,000 people. I work with a 
family practice physician, three nurse practitioners, and a 
mental health provider. We see patients of all ages.
    Providers face unique challenges while serving in rural 
areas due to accessibility and lack of resources. The 
challenges to running a successful business in healthcare can 
be just as difficult for the same reasons. The information 
highway often overlooks the side roads. In an industry full of 
rules and regulations, it is imperative to keep abreast of 
anything new coming down the pipe. Being out of the loop often 
means being left behind.
    ICD-10 has been on the horizon for several years now. We 
were ready for it, and our software vendor was ready for it. 
When the date was postponed, we moved forward. We believed the 
implementation of ICD-10 would eventually happen and that we 
would be even more prepared. With all the changes coming in 
healthcare, this was one we would tackle in full confidence. 
What we were unprepared for was how seamless it was. On a busy 
Monday morning, October 7, 2013, we took on ICD-10 and we 
haven't looked back. We did not have special training. We did 
not spend any money in preparation. We did not see less 
patients and our practice did not suffer. As providers, it was 
not frustrating or scary. It just was.
    Why did this work so well for us? A combination of things 
in our opinion, most of all teamwork and leadership. We have 
providers who work well with each other and with the rest of 
the staff. We are a close-knit medical office family, 
understanding that we are only as strong as our weakest 
employee.
    It is important to have a leader on the staff that is 
progressive and knowledgeable about what is coming, someone who 
comes prepared with a plan of action. No office should be 
without a professional practice manager, one who has 
certification to back up what years of experience has given. 
The relationship between professional practice managers and 
physicians is critical and often means the difference in 
success and failure.
    Associations such as PAHCOM offer practice managers the 
knowledge needed to navigate through the many changes in rules 
and regulations. Our industry is riddled with what you can do 
and what you cannot do. PAHCOM provides access to information 
critical to running a successful medical office.
    The other prominent factor was our software. We chose to 
implement highly effective software when we made the decision 
to transition to electronic medical records. Our practice 
manager looked at some of the things coming in the near future 
and chose software that would grow and expand to what we would 
need and that would be ready when we needed it. The road to 
ICD-10 was driven by our EHR vendor. They extended an offer to 
us to be a part of a pilot program for implementing ICD-10. We 
were very happy to be a part of it. Our thinking was, it gives 
us time to play with it and learn it before it really counts. 
We had no idea how easy it was going to be. We just wanted to 
take advantage of every possible source of information before 
each stroke counted financially. We did not feel we could be 
too prepared. We were as apprehensive as everyone else. 
Communication is the most important tool in eliminating errors, 
providing quality care and improving outcomes. There are 
several pieces that must come together, with the same 
information, in order to complete one simple procedure.
    Speaking the same language is crucial to patient care. ICD-
10 is that language. As all processes change and improve over 
time, so should our diagnosing. ICD-10 provides clear, concise 
descriptions of the problem a patient is having. The 
specifications narrow margins of error since the picture is 
clearer. The drill-down structure of the system provides an 
accurate description of the problem.
    As the world becomes ever smaller it is important to see 
healthcare with a broader view. Even in our small community, it 
is not uncommon for patients to be traveling outside of the 
country. It is important to understand that we are affected by 
the health of locations outside our homes. To speak the same 
healthcare language is imperative. As a Nation, we are behind. 
As an industry, we are behind. As healthcare providers, we can 
do better. We must be open to change and to the possibility 
that a different way can work. ICD-10 is truly better than what 
we currently have. The benefits to ICD-10 have been well touted 
as well as the drawbacks. We do not claim to have to have the 
answers or formula that will work for every provider situation 
but it worked for us.
    We used ICD-9 on a Friday and ICD-10 on the following 
Monday. We are very pleased with our decision to keep using 
ICD-10 and encourage others to support this move. Accuracy and 
positive outcomes are of course important goals in patient 
care. Fine-tuning diagnoses help paint a clearer picture of 
what is happening with a patient.
    The important thing to understand is that ICD-10 helps, not 
hinders, patient care. There are many issues that are debatable 
in healthcare today. Anything that so clearly helps the patient 
should not be one of them. ICD-10 should move forward. 
Healthcare moves fast. You cannot blink. Putting off ICD-10 is 
not blinking; it is closing your eyes.
    We do not wish to discredit rational objections to 
transitions to ICD-10. Each situation will present its own 
pains and struggles. We just wish to share our story and maybe 
ease some lingering fear. It wasn't hard, it wasn't expensive 
and it wasn't time consuming. Clinical documentation did not 
change. We spend the same amount of time documenting to support 
ICD-10 as we did with ICD-9. We did nothing different. We use 
it every day. It is a normal part of our encounter with a 
patient. The most important issue was that it was not 
disruptive to patients.
    We strongly support full implementation of ICD-10. We 
believe ICD-10 is a better communication tool and we believe it 
will truly be a benefit in the care of patients.
    Thank you again for the opportunity to share our 
experiences.
    [The prepared statement of Dr. Burke follows:]
  
  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
  
    
    Mr. Pitts. Thank you, Dr. Burke.
    The Chair now recognizes Mr. Averill, 5 minutes for an 
opening statement.

                STATEMENT OF RICHARD F. AVERILL

    Mr. Averill. 3M appreciates the opportunity to testify this 
morning.
    ICD-10: We need it. We are ready. This is the message I 
want to make sure that I convey to the committee today.
    The current system used for reporting diagnosis and 
procedures, ICD-9, was developed nearly 40 years ago. When ICD-
9 was developed, you could smoke in a patient's room. There was 
no personal computer. There was no Internet. Minimally invasive 
procedures were not even envisioned.
    ICD-9 reflects medicine of a bygone era. With ICD-9, we 
often don't know what is really wrong with the patient or what 
procedures were performed. ICD-9 codes like a repair of an 
unspecified artery by an unspecified technique are virtually 
useless for establishing fair payment levels and evaluating 
outcomes.
    I was one of the original developers of the DRGs at Yale 
University. Since the inception of the Medicaid Inpatient 
Prospective Payment System by President Reagan and Speaker 
O'Neill, I have worked with CMS to maintain and update the 
DRGs. The biggest frustration with DRG updates is that proposed 
DRG modifications from the healthcare industry often cannot 
even be evaluated because there are no ICD-9 codes available.
    Congress rightly wants to move to a healthcare system that 
focuses more on value than volume. I am here to tell you, you 
can't do that with ICD-9. You need ICD-10. It is time to have 
our diagnosis and procedure coding system reflect modern 
medicine.
    The RAND report commissioned by the National Committee on 
Vital and Health statistics concluded that the ICD-10 benefits 
from more accurate payments, fewer rejected claims, fewer 
fraudulent claims, better understanding of new procedures, and 
improved disease management would far exceed the cost of 
implementation. It is time to start realizing those benefits.
    The industry is ready. The transition to ICD-10 is 
supported by the vast majority of the healthcare community--
hospitals, health plans, coding experts, physician office 
managers, vendors, medical device manufacturers, health 
informatics specialists, and some in the physician community. 
All support the adoption of ICD-10 in October of 2015.
    Unfortunately, the uncertainty over the ICD-10 
implementation date means the whole industry has to maintain 
fully functional systems in both ICD-9 and ICD-10. Maintaining 
redundant ICD-9 and ICD-10 systems is very costly. Any further 
delay means more wasted cost. Last year's delay is estimated to 
have cost the healthcare industry $6.5 billion.
    Perhaps the biggest challenge to a smooth transition to 
ICD-10 is the uncertainty of the implementation date. It is 
simply time to end that uncertainty and allow the whole 
healthcare industry to move forward with a smooth transition.
    Questions have been raised concerning the ability of CMS to 
move forward with ICD-10. For CMS and its fiscal 
intermediaries, the implementation of ICD-10 is primarily an 
update to its claims processing system. While admittedly CMS 
has encountered some difficulties with newly constructed 
consumer-facing Web sites, CMS has extensively experience 
implementing significant updates to its claims processing 
system. As the recent GAO report demonstrates, CMS has done 
extensive ICD-10 planning, preparation, testing and outreach. 
For example, in order to facilitate vendor and hospital ICD-10 
preparation, CMS made available a fully operational version of 
the ICD-10 MSDRG software more than a year ago. Providers, 
clearinghouse, payers including CMS are all testing and will 
continue to test. Testing results show that the system is ready 
for those who have taken the time to prepare.
    As I said in the beginning, ICD-10, we need it, we are 
ready. As a member of the Coalition for ICD-10, we strongly 
oppose any further delay to the adoption of ICD-10. The 
Coalition stands ready to help in any way to ensure a 
successful transition to ICD-10 in October of 2015. Thank you.
    [The prepared statement of Mr. Averill follows:]
   
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    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes Ms. Bowman, 5 minutes for her summary.

                    STATEMENT OF SUE BOWMAN

    Ms. Bowman. Good morning. On behalf of the American Health 
Information Management Association, or AHIMA, I would like to 
thank you for the opportunity to testify today on the very 
important topic of ICD-10 implementation.
    Implementation of ICD-10 is long overdue. Never before in 
U.S. history has the same version of ICD been used for more 
than 30 years. ICD-9 is obsolete and no longer reflects current 
clinical knowledge, contemporary medical terminology or the 
modern practice of medicine.
    U.S. healthcare data is being allowed to deteriorate while 
the demand continues to increase for high-quality data, data 
that can support healthcare initiatives such as the meaningful 
use of electronic health record Incentive Program, new payment 
models, and other initiatives aimed at improving quality and 
patient safety and decreasing costs. ICD-10 also improves 
tracking and surveillance of pandemic threats such as Ebola, 
which does not have its own ICD-9 code.
    The number of ICD-10 codes has been raised as a concern. 
The expanded clinical detail in ICD-10 was requested by the 
medical community because these clinical distinctions were felt 
to be important to capture. A number of physician organizations 
continues to actively participate in the ongoing maintenance of 
ICD-10 by requesting additional clinical detail. Ninety-five 
percent of the requests for new ICD-10 comes have come from the 
medical community, especially the physician organizations.
    Just as the size of a dictionary or phone book does not 
make it more difficult to look up a word or a phone number, an 
increased number of codes does not make it harder to find the 
right code. Increased specificity, clinical accuracy, and a 
logical structure actually facilitate rather than complicate 
the use of a code set. Also, no individual provider will use 
all of the ICD-10 codes but rather he will use a subset of 
codes applicable to his clinical practice and patient 
population. And nearly half of the increase in codes is due 
solely to the capture of the side of the body affected by the 
clinical condition.
    The specificity of the external cause codes has also been 
raised as a concern. External cause codes, or the reason why an 
injury occurred, are not unique to ICD-10. They exist in ICD-9 
as well. Many providers are not currently required to report 
external cause codes unless a provider is subject to a State-
based external cause code reporting mandate or these codes are 
required for a particular patient circumstance. Reporting of 
external cause codes in either ICD-10 or ICD-9 is not required. 
And even when external cause codes are required, many of them 
are for use in very specific circumstances. Most providers have 
probably had no occasion to assign the existing ICD-9 code for 
an accident involving injury to the occupant of a spacecraft 
but the fact that such a code exists has not made ICD-9 more 
difficult to use.
    Many small providers have been concerned about anticipated 
high cost and complexity of the ICD-10 transition. However, 
recent data such as the results of a survey of small physician 
offices conducted by the Professional Association of Health 
Care Office Management, or PAHCOM, that were just released 
yesterday, have shown the cost and burden to be much less than 
earlier predictions. And physician practices do not need to 
implement the ICD-10 procedure code or ICD-10 PCS as CPT codes 
will continue to be used to report physician and outpatient 
services.
    Training is one of the factors in the cost of 
implementation but the extent of ICD-10 training needed depends 
on the individual's role. Physicians will primarily require 
education around the clinical documentation needed to support 
ICD-10 codes. Additional documentation requirements have often 
been cited as a major contributor to the cost of ICD-10 
implementation. However, even without the ICD-10 transition, 
there is a growing demand for more complete and accurate 
documentation, and the impact of clinical documentation 
improvement efforts can be mitigated through the use of 
electronic documentation capture tools such as documentation 
prompts in electronic health record systems. Also, many of the 
clinical details found in ICD-10 are typically already 
documented such as laterality.
    Free and low-cost ICD-10 educational implementation 
resources are widely available from multiple sources, giving 
all stakeholders the ability to be fully ready by the 
compliance date. Each delay in ICD-10 implementation has taken 
an enormous toll on the healthcare industry including 
significant additional costs, diversion of ICD-10 budgets and 
personnel, lack of employment prospects for students trained in 
a code set not yet in use, and many lost opportunities to use 
better data to improve health care and reduce costs.
    The healthcare industry has had more than 6 years to 
prepare. It is time to stop delaying the transition to ICD-10. 
We need ICD-10, and we are ready.
    Thank you for the opportunity to testify.
    [The prepared statement and additional material submitted 
by Ms. Bowman follow:]


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    Mr. Pitts. Thank you, Ms. Bowman.
    At this point the Chair recognizes Ms. Matus, 5 minutes for 
her summary.

                  STATEMENT OF KRISTI A. MATUS

    Ms. Matus. Chairman Pitts, Ranking Member Green, members of 
the subcommittee, thank you for this opportunity to share our 
perspective on the important issue of ICD-10 implementation and 
its implications for our broader, bipartisan health reform 
efforts.
    My name is Kristi Matus, and I am the Chief Financial and 
Administrative Officer for Athena Health, a provider of cloud-
based health information technology services to more than 
60,000 care providers nationwide in all 50 States, connecting 
care for over 60 million patients.
    Every one of our clients is on a single national Internet-
based network that we use to connect with them in real time on 
a daily basis like Amazon, Facebook or Google. As you may know, 
this is a paradigm that is all too rare in health care.
    Based on our experience with partnering with medical 
practices to improve efficiency and outcomes, our point of view 
is simple: it is decision time. Maintain the current date for 
ICD-10 implementation or cancel it once and for all. Do not 
allow another delay.
    Our Nation has an extraordinarily ambitious, largely 
bipartisan healthcare agenda. From the effort to transition the 
Nation's care providers to modern technology to the clear 
imperative of shifting from a costly fee-for-service model to 
value-based delivery payment structures, we have collectively 
resolved to tackle a series of very difficult complex problems, 
all with the idea of reducing costs and taking better care of 
patients. To cite just one particularly timely example, the 
21st Century Cures package of initiatives championed by many on 
this committee has tremendous potential to improve health care, 
but many of its components assume and depend upon continued 
technological evolution.
    I am not here to tell you that ICD-10 is a silver bullet, 
but on the spectrum of the challenges we face in health care, 
ICD-10 is a relatively easy one, the technological equivalent 
of an upgrade from a simple dictionary to a more complex one. 
It will be orders of magnitude less difficult than achieving 
the changes in human behavior necessary for the Meaningful Use 
program to succeed or implementing the fundamental evolution in 
healthcare business models necessary for truly accountable 
care. Repeatedly delaying the implementation of relatively 
simple changes calls into question whether we as a country are 
truly committed to improving health care and potentially 
undermines the success of our national healthcare agenda.
    Fortunately, we know that ICD-10 is absolutely possible. 
Much of the developed world has made the switch years ago 
including, for example, the Czech Republic, Korea and Thailand, 
where, according to the World Bank, the average annual 
healthcare spend per capita is $215 compared to nearly $9,000 
in the United States.
    At Athena Health, we have already completed the work 
necessary to ensure that our clients were ready for last year's 
deadline as they will be ready for this year's. In fact, we 
financially guarantee ICD-10 readiness for each of our tens of 
thousands of clients. We are not the only solution.
    Many of our clients practice in exactly the kinds of small 
medical groups that have expressed significant concerns about 
the changes required to adapt to ICD-10. Each new delay only 
multiplies the financial and emotional cost of such practices, 
who struggle not only with the implications of a possible code 
switch but with the persistent uncertainty created by repeated 
delays. Fear creates stasis, inhibiting progress not only on 
ICD-10 but also on the other more important systemic reforms 
that I discussed a few moments ago.
    Athenahealth clients have no reason to fear. Because we are 
Internet based, we will throw a virtual switch at the moment 
ICD-10 requirement goes into effect, and every one of our 
clients will be upgraded at that same moment.
    There is a solution to the perceived ICD-10 problem, and we 
certainly are not the only ones that can provide it. Repeated 
delays of supposedly firm deadlines both in ICD-10 and in other 
health IT programs like Meaningful Use make it all too easy for 
some in our industry to doubt future deadlines. Delays 
unintentionally create incentives for some vendors to forego 
the work necessary to prepare for ICD-10, confident that their 
failure to prepare will not harm their clients because we will 
continue to kick the can and not really move forward with 
reforms necessary to improve efficiency and patient care. This 
is a damaging cycle of nonperformance that will only be broken 
when the Government resolves to stick to the deadlines it 
communicates.
    Either ICD-10 is worth doing or it is not. If it is, then 
stick to the deadline this year. There will be some disruption 
but our industry and the Nation's care providers will respond 
and adapt. If you conclude that the benefits of ICD-10 do not 
outweigh the potential risks, then cancel the program and focus 
legislation more aggressively on the few fundamental changes in 
health care that are necessary to cure our current 
dysfunctional system.
    On behalf of Athena Health's 60,000-plus care provider 
clients and their many thousands of colleagues, I urge you in 
the strongest possible terms, do not again kick this can down 
the road. Pull the trigger or pull the plug.
    Thank you.
    [The prepared statement of Ms. Matus follows:]
 
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    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes Ms. Bocchino, 5 minutes for your opening statement.

                 STATEMENT OF CARMELLA BOCCHINO

    Ms. Bocchino. Thank you. Good morning, Chairman Pitts and 
Ranking Member Green and members of the subcommittee. I am 
Carmella Bocchino, Executive Vice President of America's Health 
Insurance Plans, the trade association for the health insurance 
industry. I appreciate the opportunity to testify about the 
importance of implementing the ICD-10 system on October 1st 
without any further delay.
    I think everyone here today agrees that we need more value 
in our Nation's healthcare dollar and we need a 21st century 
healthcare system. To support this goal, our members believe it 
is critically important for the healthcare system to move 
forward now with the ICD system to deliver greater value for 
consumers and improvements in quality improvement, and 
implementing ICD-10 under the current timetable will establish 
a strong foundation for allowing health plans and providers to 
identify and report conditions and medical treatments in more 
specific ways, ultimately leading to more effective measures of 
quality and health outcomes.
    Delaying implementation will increase cost and impose 
significant administrative challenges across the entire 
healthcare system. Our industry processes millions of claims, 
eligibility requests, payments and other administrative and 
clinical transactions on a daily basis. Recognizing the 
migration to the ICD-10 code set has a major impact on all 
these activities. Our members have devoted a tremendous amount 
of time and resources to be ready by October 1, 2015. This 
includes extended outreach to healthcare providers as well as 
their vendors, working with them to provide education and 
implementation tools, crosswalks, practice management upgrades, 
and instructions and appropriate coding based on the provider's 
area of practice.
    Our written testimony provides specific examples of steps 
many of our members are taking to prepare for ICD-10 
implementation. For example, completed internal systems testing 
to assure successful use of ICD-10 on all claims and other 
transactions and engage with providers, hospitals and physician 
groups and their vendors to do this external testing, ensuring 
end-to-end testing of submitted claims. We have conducted 
readiness surveys to assess partners' familiarity with the 
coding system and the expected process for submitting compliant 
transactions and to see what support is continued to be needed, 
developed informational articles and resource materials that 
provide detailed information for healthcare providers on ICD-10 
and how to incorporate the new coding system into their 
practices. They have updated clinical policies to reflect the 
new ICD-10 codes and provided this information to their 
healthcare provider partners. And some members have actually 
established a professional readiness portal for ICD-10 that 
allows hospitals, medical group systems, clearinghouses and 
individual providers to engage in testing and check their own 
readiness by submitting claims based on specific episode-of-
care scenarios. These activities have been supplemented by 
significant efforts undertaken by HHS Road to 10 Initiative and 
private stakeholders as the American Health Information 
Management Association, many professional societies and others.
    From a quality improvement perspective, ICD code sets 
provide substantial more specificity and precision in defining 
a diagnosis or procedure. It will make it easier for healthcare 
providers and researchers to identify the correct code for a 
diagnosis or procedure and document medical applications. This 
expanded detail compared to the ICD-9 system is a fundamental 
building block for payment reform and will enable providers and 
payers to track health outcomes more effectively.
    Because the ICD-10 system offers more granularity to 
identify disease, public health surveillance will be better 
equipped to analyze and interpret data, thereby providing early 
warning signals for impending public health emergencies, 
monitoring the epidemiology of public health problems, and 
informing public health policy.
    In closing, I want to note that ICD-10 already has been 
delayed three times, as has already been stated. Another delay 
would bring significant cost and additional administrative 
challenges for health plans and providers that have been and 
are ready to implement, penalizing those who have invested the 
time and resources necessary to implement on time. Further 
delays also would prevent providers and payers from leveraging 
ICD-10 to improve patient care and quality outcomes.
    Without the more accurate, reliable data that will be 
facilitated by ICD-10, ongoing efforts to a transition to a 
payment system based on quality and outcomes would not achieve 
their full potential. These outcomes both in terms of financial 
cost and lost opportunities are unacceptable.
    For that reason, we strongly urge the committee to support 
the current schedule of implementing ICD-10 codes on October 
1st.
    [The prepared statement of Ms. Bocchino follows:]
 
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    Mr. Pitts. The Chair thanks the gentlelady and now 
recognizes Dr. Terry, 5 minutes for your summary.

           STATEMENT OF WILLIAM JEFFERSON TERRY, SR.

    Dr. Terry. Chairman Pitts, Ranking Member Green, members of 
the subcommittee, my name is Dr. Jeff Terry, and I am 
testifying today as a member of the American Urological 
Association and as a practicing urologist who puts in 13 hours 
a day taking care of patients in Mobile, Alabama. We thank you 
for this hearing very much.
    The AUA has a membership of 18,000 physicians and is also a 
member of the Alliance of Specialty Medicine. During the last 
Congress, I had the privilege of moderating an Alliance 
roundtable on ICD-10 where members of CMS were actually 
present.
    The AUA enters this debate on ICD-10 as an advocate for the 
patients and the physicians. As you hear testimony today, keep 
in mind the concerns of practicing physicians who want to 
preserve the all-important patient-physician relationship and 
don't put the computer and statistics in the middle of this 
relationship.
    I know that you will weigh any proven patient care 
advantages of ICD-10 against the consequences of a flawed 
implementation. Ultimately, the benefits should outweigh the 
risks.
    The ICD system was designed for the purposes of gathering 
statistical and epidemiological data. The United States is the 
only country that uses it as part of the billing system. ICD-10 
is planned to replace ICD-9 all in one day. Our present system 
has 13,000 codes where ICD-10 will have anywhere between 68,000 
and 87,000 codes, and the United States is the only country 
that uses all of these codes. The other countries use about a 
fifth of that number. Experts estimate physicians should plan 
on a 3 to 4 percent increase in time per patient encounter 
merely to document the correct code. The coding guidelines for 
ICD-10 are more complex, and those who do not fully understand 
them will fail to document correctly and not be paid.
    Proponents of ICD-10 say the increased specificity will 
improve clinical data and improve quality. These potential 
benefits are not documented. However, the cost of ICD-10 is 
well documented for physicians who already face increased cost 
in complying with EHR incentive programs, the PQRS Quality 
program, the Value-Based Payment Modifier Program, not to 
mention the annual threat of SGR cuts and the 2 percent 
sequestration cut that we already have.
    Now we are faced with the costly unfunded mandate of ICD-10 
that will certainly put some physicians out of business. 
Physicians are overwhelmed with the tsunami of regulations that 
have significantly increased the work for our practices. 
Physicians are retiring early, which could leave countless 
number of patients without a doctor. Based on data in other 
countries, all physicians will be forced to reduce the number 
of patients that they see when ICD-10 is implemented, which can 
last for more than a year, resulting in less efficient 
practices and making it difficult for patients to get the care 
they need.
    An independent study last year found significant cost 
associated with upgrading the hardware, the software, the 
training of personnel and the conversion of ICD-10 ranging from 
$50,000 to $250,000 for small practices and several million 
dollars for large practices. CMS states that physician consider 
getting a line of credit to cover cash-flow problems and 
expenses. Others have suggested the need for a 3- to 6-month 
cushion. This is not possible for most practices that have very 
few assets to quality for these significant loans.
    While CMS is in the midst of end-to-end testing, it is 
primarily being conducted by volunteers who are prepared. We 
worry that these results do not paint an accurate picture of 
the current state of provider readiness.
    Ladies and gentlemen, no matter what the coalition or the 
coding industry says, the vast majority of America's physicians 
in private practice are not prepared for this ICD 
implementation all in one day. The continual threat of Medicare 
payment reductions, the time-consuming CMS quality programs, 
the new EHR systems, Medicare compliance programs occupy 
physicians so much that they don't have the time or resources 
to prepare for ICD-10. It is harder and harder to keep the 
patient as the primary focus in our daily activities. ICD-10 is 
viewed as another expensive distraction with little 
demonstrated value to improving patient care. The huge costs 
certainly outweigh the very few benefits as far as patient care 
is concerned.
    Our focus today is not centered solely on the financial 
investment made by large health insurers, health systems and 
other entities preparing for this transition. Our focus is 
about our Government providing an environment where physicians 
and healthcare professionals can devote all of their energies 
to medical issues for the benefit of their patients. To that 
end, I urge Congress to delay implementation of ICD-10 and 
appoint a committee to better study the risks and the benefits 
with the patient in mind. If a delay is not possible, then 
consider a dual ICD-10 option permitting physicians to make the 
transition so we can survive in our practices.
    Thank you so much for your commitment and your leadership 
on this issue. ICD-11 is probably 5 years away so we need a 
policy for appropriate coding transitions in order to avoid 
this problem again.
    I am happy to answer any questions that you see fit.
    [The prepared statement of Dr. Terry follows:] \1\
---------------------------------------------------------------------------
    \1\ Additional material submitted by Dr. Terry has been retained in 
committee files and also is available at  http://docs.house.gov/
meetings/IF/IF14/20150211/102940/HHRG-114-IF14-Wstate-TerryW-20150211-
SD001.pdf. 

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    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes Dr. Hughes, 5 minutes for your opening statement.

                  STATEMENT OF JOHN S. HUGHES

    Dr. Hughes. Thank you, sir. Mr. Chairman and members of the 
committee, first let me just interject that I very respectfully 
appreciate Dr. Terry's comments about the stresses of the 
regulatory burden placed on physicians, but I would offer that 
ICD-10 is not the major problem and is probably a trivial 
problem compared to the other issues that confront practices 
today.
    I am a general internist. I am Professor of Medicine. I 
teach medical students and medical residents. I see patients on 
my own and I conduct research in areas of quality assurance.
    One of the research areas I have focused on is the study of 
complications of care, with the view that if we can accurately 
identify the factors and circumstances that account for 
complications, then we will be able to reduce their occurrence. 
In fact, several States, Maryland for one, are now adjusting 
hospital payments based on some of this research.
    The usefulness and reliability of this kind of research 
depends very much on how precisely we can identify the 
specifics of the complication and exactly how they are treated. 
Although we have made considerable progress in addressing 
complications, other quality issues in the past several years, 
complication rates remain unacceptably high. The ICD-9 coding 
system fails to provide the level of detail needed to expand 
these efforts. I have been personally frustrated many times at 
ICD-9's inability to specify the exact nature of a 
complication, its extent, its location, and how it was treated.
    Now, as an example, let me ask you to consider a 74-year-
old man who fell, sustaining a puncture wound that severed his 
left femoral artery. He was rushed to surgery, where the 
damaged portion of the artery was replaced with a synthetic 
graft. These events are coded in ICD-9 as a diagnosis of 
``injury to the common femoral artery'' and the procedure code 
is ``resection of vessel with replacement.'' There is no 
mention that the injury was a major laceration on the left 
side, or that the type of replacement was a synthetic graft, 
all of which is included in the ICD-1.
    This lack of detail is even more obvious when it comes to 
complications. Consider the same man developed bleeding at the 
site of the graft on the day after surgery. He was returned to 
the operating room, his incision was reopened and the graft 
repaired at the site of the leak. ICD-9 codes this as 
``mechanical complication of other vascular device or implant 
or graft'' and the procedure code is ``revision of vascular 
procedure.'' So all we know is that there has been some type of 
complication that required some type of surgery, and that is 
about it. The ICD-10 code provides a much more complete 
picture, telling us that the complication was a hemorrhage, 
exactly where it occurred, and that the revision was a re-
suture of the graft using an open approach. This is but one 
example. There are numerous throughout the ICD-9 system, and 
the benefits of the ICD-10 providing the extra detail.
    Another major flaw in ICD-9 is that it does not have the 
capacity to expand to provide new codes describing new 
treatments and technologies. This means that new techniques 
such as minimally invasive surgery, which have been 
increasingly and successfully used in cardiac surgery, and are 
rapidly expanding into other surgical fields, cannot be 
adequately described using the simplistic four-digit and 
sometimes five-digit structure of ICD-9. Minimally invasive 
surgeries use smaller incisions, which results in fewer 
complications, less discomfort, more rapid healing and shorter 
hospital stays.
    Now, we don't need ICD-10 in order to do minimally invasive 
surgery but these new procedures will not be adequately 
described if we continue to use ICD-9. They will have to be 
described in general terms or they will have to be included in 
codes that contain open surgical approaches, resulting in 
insufficient detail to track their increasing use.
    The structure of ICD-10 allows this important information 
to be captured in a systematic manner, and can be readily 
expanded to incorporate descriptions of new discoveries and 
treatments when they become available. This capacity is 
critical to track and assess the efficacy of these new 
technologies.
    Thank you very much.
    [The prepared statement of Dr. Hughes follows:]

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    Mr. Pitts. The Chair thanks the gentleman. Thank you all 
for that excellent testimony. I will begin the questioning and 
recognize myself for 5 minutes for that purpose.
    I would like to ask a series of questions to all of you, so 
please respond yes or no to these, and we will just go down the 
line. We will start with you, Dr. Burke.
    In your opinion, do you believe we are ready for ICD-10 
implementation, yes or no?
    Dr. Burke. Yes.
    Mr. Pitts. Mr. Averill?
    Mr. Averill. Yes.
    Mr. Pitts. Ms. Bowman?
    Ms. Bowman. Yes.
    Mr. Pitts. Ms. Matus?
    Ms. Matus. Yes.
    Mr. Pitts. Ms. Bocchino?
    Ms. Bocchino. Yes.
    Mr. Pitts. Dr. Terry?
    Dr. Terry. No.
    Mr. Pitts. Dr. Hughes?
    Dr. Hughes. Yes, sir.
    Mr. Pitts. All right. Thank you. Again, all of you, in your 
opinion, should Congress oppose attempts to delay ICD-10 
implementation? Dr. Burke?
    Dr. Burke. No.
    Mr. Averill. It was a double negative.
    Mr. Pitts. Let me repeat the question. In your opinion, 
should Congress oppose attempts to delay ICD-10 implementation?
    Mr. Averill. They should oppose.
    Mr. Pitts. Yes. OK.
    Ms. Bowman?
    Ms. Bowman. Yes.
    Mr. Pitts. Ms. Matus?
    Ms. Matus. Yes.
    Mr. Pitts. Mrs. Bocchino?
    Ms. Bocchino. Yes.
    Mr. Pitts. Dr. Terry?
    Dr. Terry. No, sir.
    Mr. Pitts. Dr. Hughes?
    Dr. Hughes. Yes.
    Mr. Pitts. All right. Again, down the line, Dr. Burke, we 
will start with you. In your opinion, what impact would delay 
have on your industry and the patients you serve? You can 
elaborate a little bit.
    Dr. Burke. Well, I think, you know, the ICD-10 is a very 
good communication tool. Either you can use the ICD-10 code or 
you would have to use it in your plan. You would have to type 
out everything in your plan, so actually it flows a lot more 
smoothly.
    Mr. Pitts. OK. What impact would delay have on your 
industry or patients you serve, Mr. Averill?
    Mr. Averill. Well, certainly it would dramatically increase 
the cost of being prepared to ultimately move forward. It would 
also continue to compromise our national data in terms of 
having the necessary information to evaluate many of the things 
that the panel talked about, and so what is most concerning to 
me is the dramatic increase in cost of any delay.
    Mr. Pitts. Mrs. Bowman?
    Ms. Bowman. I would say certainly the cost. Our members are 
health management professionals who have been trained and 
retrained and have to keep their training updated to maintain 
their skills for whenever ICD-10 is implemented so the cost and 
also I would agree with Rich's comment about the delay and 
being able to use the better delay.
    Mr. Pitts. Mrs. Matus?
    Ms. Matus. Countless care providers, hospitals and other 
institutions have already put untold thousands of dollars into 
preparing for ICD-10, so those are the hard costs. The soft 
costs of, you know, the uncertainty which is magnified by each 
delay is unquantifiable.
    Mr. Pitts. Mrs. Bocchino?
    Ms. Bocchino. So I will echo what others have said but I 
will also add that a lot of times additional documentation is 
required by providers under ICD-9 in order to process a claim. 
Because of the specificity of the ICD-10 codes, much of that 
documentation will go away and therefore we believe it will 
actually reduce some of the burden on providers.
    Mr. Pitts. Dr. Terry?
    Dr. Terry. I know I am in the minority on this panel but I 
want you to know, I represent thousands of doctors. Speaker 
Boehner has four boxes of thousands of letters in his office on 
this subject. I have some at the table.
    You know where I stand. It has the potential to do 
irreparable harm to the patients and the physicians who can't 
implement this the way industry wants us to. You know, we don't 
treat by statistics. I mean, this is just something that gets 
in our way of taking care of our patients, and it has to be 
done the right way.
    Mr. Pitts. All right. Dr. Hughes, what impact would delay 
have on your industry or patients you serve?
    Dr. Hughes. I agree that this has to be done in the right 
way. Delay means a couple things. One, if physicians are 
interested in keeping up with what is happening and learning 
the effectiveness of new treatments, we need to have better 
data. So that will--if we don't implement this, we are not 
going to be having the optimum amount of data.
    Mr. Pitts. All right. We are going to have to keep going. I 
have a couple more questions.
    Dr. Burke, does ICD-10 bring any value to the patient 
community? It is one thing to improve systems operations for 
insurers and hospitals but how does this matter to patients?
    Dr. Burke. I think, you know, for instance, if you use an 
ICD-9 code and a patient calls a couple days later, like if 
they come in with leg pain, you know which leg it is. You will 
have to ask them again where their pain was, but if you use an 
ICD-10 code, you can actually localize the pain to either 
extremity. So it is a lot better communication tool.
    Mr. Pitts. Now, we heard a little bit mentioned about ICD-
11. Ms. Matus, what are your thoughts on, you know, just wait 
for it instead of forcing people to go through ICD-10?
    Ms. Matus. So, you know, again, we think this is either 
important to do or it is not. If we were convinced that the 
United States that we as a group would take a leadership 
position in moving forward with ICD-11, then maybe miss ICD-10. 
But without a firm commitment to be the leaders in a new coding 
methodology that is still 5 years away and frankly needed 
today, that seems like a bridge too far.
    Mr. Pitts. All right. My time is expired. Let me make it 
clear as chairman of this subcommittee, I support ICD-10, 
moving forward to ICD-10 rather than another delay. We need to 
end the uncertainty, in my opinion, move forward to full 
implementation of ICD-10.
    At this time I will recognize the ranking member, Mr. 
Green, 5 minutes for questioning.
    Mr. Green. Thank you, Mr. Chairman. I would like to ask 
unanimous consent to submit for the record the article showing 
ICD-10 implementation cost in small physician practices are 
dramatically lower than expected.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Green. Thank you, Mr. Chairman.
    Dr. Terry, I know that you, coming from Texas, you probably 
feel like you are the Alamo.
    Dr. Terry. I have my Kevlar suit on.
    Mr. Green. And I appreciate urologists. I work a lot like 
all of our committee members on the committee work a lot with 
our specialties because delivery of health care. The biggest 
issue I hear from them is not ICD and obviously it is SGR, and 
I have served with some really great members from Mobile. You 
have a beautiful city. Sonny Callahan was a good friend and Joe 
Bonner, and you have a history of sending good hardworking 
Members to Congress from Mobile.
    Mr. Averill, you mentioned that ICD-10 testing is still 
ongoing. For those who are preparing the transition, do you 
expect ICD-10 implementation to run smoothly come October 1st?
    Mr. Averill. Yes, I do. I think there has been extensive 
opportunity both on the commercial payer side and the CMS side 
to do end-to-end testing. CMS has a whole series of end-to-end 
opportunities for those who are prepared and are willing to 
participate.
    I want to emphasize that for CMS, this is a relatively 
routine update to their claims processing system. This is their 
core competency. I submitted in my testimony that they have had 
some difficulties with consumer-facing Web sites but this is 
their core competency, namely updating the claims processing 
system.
    Mr. Green. Well, I hope they are doing some run-throughs 
before October 1st so we don't have what we had when some of us 
wanted the Affordable Care Act to roll out much more easily.
    What about those folks who haven't begun to prepare for 
transition? Can they still be ready by October 1st? Here we are 
in February.
    Mr. Averill. I have been very impressed with how the market 
has responded with educational material out there, much of it 
for free. The market has really responded. Most vendors have 
converted their systems to ICD-10 and are by and large making 
that available to their clients for free, and so the whole 
infrastructure is there on a much more sophisticated basis than 
it was even 1 or 2 years ago, so I remain confident that those 
who are lagging behind at this particular point in time if they 
are willing to expend some effort to get prepared, those 
resources are readily available.
    Mr. Green. I have another question for you, and I only have 
a couple minutes left. You testified the effect of the current 
ICD-9 coding system with diagnostic related groups, or DRGs. 
DRGs are used to classify hospital cases into groups for the 
purpose of reimbursement. Does the fact that ICD-10 is almost 
40 years old have an effect on DRGs?
    Mr. Averill. Absolutely. As I said, it is not uncommon to 
have reasonable requests from the industry suggesting an MS DRG 
change. Very often if you look at the Federal Register, you 
will see CMS saying we had this suggestion, unfortunately we 
weren't able to evaluate it because there is no ICD-9 codes to 
evaluate that particular aspect.
    Mr. Green. Who is most affected if the DRGs aren't modified 
property?
    Mr. Averill. Well, I think the whole industry is--
hospitals' financial viability, reputations of individual 
institutions because they are often used for evaluating--or a 
component of evaluating quality of care. I think it is 
pervasive throughout the industry. It is absolutely critical 
that we keep MS DRGs up-to-date and reflective of today's 
medicine.
    Mr. Green. Ms. Bowman, what types of training and resources 
go into preparing for ICD implementation and what is the cost 
of delaying?
    Ms. Bowman. The cost of the training that goes into 
implementation has to do primarily with training coders on 
using the code sets and other users in understanding what the 
changes in the data are going to look like after the code sets 
are implemented, and also changes to systems and those 
personnel in understanding what changes need to be made.
    Also, a big factor is clinical documentation improvement, 
and so I would say the biggest factors are probably training 
coders and then training physicians on improving their clinical 
documentation, but we found that there is a growing marketplace 
for tools in helping with the clinical documentation 
improvement because ICD-10 actually lends itself better because 
of its logic and specificity for those types of tools so that 
is turning out to be not as burdensome as some had feared 
initially.
    Mr. Green. Thank you, Mr. Chairman.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the Chair Emeritus of the full committee, Mr. Barton 
of Texas.
    Mr. Barton. I thank you, Mr. Chairman, and I appreciate you 
holding this hearing. I think it is good to have transparency.
    I would point out, in our memo for this hearing, we have a 
coding error. The memo talks about that the International 
Statistical Institute began in 1891 to begin the process of 
creating an internationally recognized classification of 
diseases. That is pretty cool. A hundred and 16 years ago they 
started doing that, so we have our own coding problems on the 
committee staff.
    But in any event, I think it is pretty obvious when the 
committee chair or the subcommittee chairman says that he 
supports this, and he is the chairman, and the ranking member 
seems to support it, that we are supportive. I haven't had a 
chance to talk to either of those gentlemen, and I am not 
opposed to going to ICD-10 but I do have some concerns, and 
they are more at the CMS level than the panel, but I don't see 
why it has to be an either/or. I don't see why CMS has to 
arbitrarily say this is going to be the way it is come hell or 
high water.
    I don't know enough about the coding systems and the 
computer programs and all that. I would have thought that ICD-
10 would build on ICD-9 and that they would be compatible so 
that you didn't have to choose. Dr. Terry, is that not true? I 
mean, are they so different that you couldn't use either one or 
the other?
    Dr. Terry. Well, the codes are very different. Yes, sir, 
they don't--I mean, it is just not an exponential increase in 
the codes but it is a mindset. It is different rules. It is 
just totally different.
    Mr. Barton. I don't have my Congressional phone with me. 
This is my campaign phone. It is an iPhone. My Congressional 
phone is still a BlackBerry, and nobody made me switch to this 
phone for campaign purposes. As all the members up here know, 
we have to separate our campaign communications from our 
Congressional, and the iPhone seemed to be better, and so that 
is what the campaign bought. But there is no FEC law that says 
I have to. If I still wanted to use a BlackBerry on the 
campaign, I could.
    I will ask the doctor on the end here, I can't see your 
nameplate, sir, but I listened to you. Why couldn't CMS provide 
incentives to switch to--our Medicare, for that matter--to 
switch to ICD-10 by payments, but if a family practitioner or a 
doctor in a small practice didn't have the money or didn't want 
to, you know, let them use ICD-9 and not--they might not be 
reimbursed as much but they could still get something, and if 
you were in a more specialized practice that needed more 
complicated codes, do it that way so it is not an either/or.
    Dr. Hughes. I am not a health economist or an 
administrator. The idea of incentives is inherently appealing 
to me, but I don't know, it seems to me like that would cause 
lots of duplication of effort on the part of CMS, which might 
be prohibitively expensive, but that is just a question I am 
raising. I can't answer that question definitely. Some of the 
other folks on the panel may be able to.
    Mr. Barton. Well, my point is, you know, you can make 
things happen by punitive measures or you can make things 
happen by incentives, and in this case, it looks like we are 
trying to be punitive by saying no matter what, you have to do 
it, and I don't know for the life of me if I am in whatever 
business I am in, if I want to conduct my business on way, I 
know I may be penalized by not being reimbursed as much or not 
getting as timely a payment or something, but you know, I don't 
know why we have to force people into a system that for 
whatever purpose they just don't feel like they are ready to go 
to.
    Dr. Burke, do you have any comments on that?
    Dr. Burke. I would say just in general, I mean, ICD-10 is a 
lot better program than ICD-9. I mean, it makes it easier to 
find the diagnosis, so actually would probably spend less time 
in the room with the patient with an ICD-9 code.
    Mr. Barton. Well, from an insurance perspective and from a 
data information perspective, I agree with you, it is more 
specific and all that, but from a practitioner perspective, I 
am not sure that I am following that. I would like to see CMS 
work with the user community at the provider level and come up 
with a way to incentive it without telling them they had to do 
it.
    With that, Mr. Chairman, my time is expired and I yield 
back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the lady from Florida, Ms. Castor, 5 minutes for 
questions.
    Ms. Castor. Well, thank you very much, Mr. Chairman, and 
thank you to our experts for your testimony here today.
    So what I understand is the International Classification of 
Diseases coding system number 9 has been in place in the United 
States since 1979. In 1990, a new classification system, number 
10, was adopted. In 1996, the Congress gave general direction 
for the United States to move towards that coding system. While 
the United States has delayed it for many, many years, 38 other 
countries have transitioned to that modern ICD-10 coding 
system.
    The United States is typically a world leader but it 
appears that unfortunately that is not the case when it comes 
to the modern coding system, and the problem is that based on 
all the evidence I have seen, that has been very costly for our 
country and for practitioners. A number of studies have 
concluded--HHS did an analysis in 2014, the RAND Corporation 
did an analysis, and we are working about billions of dollars 
in the American healthcare system, and many of you have 
testified today about the cost. So I would like to join my 
colleagues in urging no more delays in the transition to ICD-
10, and especially I urge the leadership not to include delays 
in must-pass bills, especially something as important as how we 
pay doctors that see Medicare patients. Let us stick with the 
October 1st deadline.
    Another reason is since 1979, think about the changes in 
health care that has been mentioned today. New medical devices, 
new treatments have been developed, and our coding system has 
to reflect modern medicine. The consensus, as I understand it, 
is more specific codes will help us make great strides in 
healthcare quality, and all of you have mentioned how important 
it is for America to transition from paying for quantity of 
care to quality of care, and it appears to me that more 
specific data will help payers implement incentives for better 
patient outcomes. Better specificity will help the providers 
who we are increasingly holding accountable for patient safety, 
readmission rates, patient outcomes.
    So I would like to focus on a couple of things. I also 
heard Dr. Hughes testify that the change in the codes will be 
important to improvements in research, the importance of 
identifying factors and circumstances that account for 
complications of care in order to reduce their occurrence. Can 
you talk a bit more about how ICD-10 will help with research 
initiatives?
    Dr. Hughes. The kind of research that I do and many other 
people do in attempts to improve quality all depends on data. 
That is what is needed. It has to be accurately recorded. It 
has to be precise enough that actually makes some difference, 
that it is specific enough, and with specific-enough data, you 
can track patterns, you can track the introduction of new 
procedures, and all that makes the quality of the research much 
better and makes the results more accurate.
    Ms. Castor. How does it make the quality much better in the 
long run?
    Dr. Hughes. Well, because you are able to identify specific 
actions, you are able to identify specific new procedures. When 
you have a new type of minimally invasive procedure, for 
example, you don't have to categorize that as another open 
procedure or ICD-9 to categorize those new procedures as other 
types of cardiac surgery.
    Ms. Castor. What type of diseases are you talking about?
    Dr. Hughes. Well, here I am talking about cardiac surgery 
on the procedure side, but the new procedures are being 
expanded into gastrointestinal surgery, to lung surgery, you 
name it. There are illnesses on the diagnosis side. There are 
illnesses that arise or illnesses that differentiate. We have 
new categories of malignancies.
    Now, you can always add an ICD-9 code but at this point we 
are pretty full. ICD-9 really has not that many more codes that 
you can cram new information into so you have to add a code 
that is out of--you know, put it in a different chapter or you 
have to lump it in with a whole lot of other things. So the 
specificity can make a whole lot of difference in terms of 
tracking illness and tracking new interventions.
    Ms. Castor. Thank you very much.
    Mr. Pitts. The Chair thanks the gentlelady and now 
recognize the vice chair of the committee, the gentleman from 
Kentucky, Mr. Guthrie, 5 minutes for questions.
    Mr. Guthrie. Thank you, Mr. Chairman, and I want to start 
with Dr. Burke.
    I have talked to different people about ICD-10 conversion, 
and we went to estimate to cost to implement this, as much as 
$84,000 and as low as a few thousand dollars. Could you help 
the committee understand what actual costs are faced by the 
doctors' offices as we move forward?
    Dr. Burke. That is a good question. I don't know, because 
for us, it didn't cost anything. You know, it was just another 
day in the office, you know. Day one we were using ICD-9, the 
next day we were using ICD-10.
    Mr. Guthrie. No cost to transfer over?
    Dr. Burke. No, no. Our software vendor was the primary 
factor in getting that done but, you know, there is no cost to 
us.
    Mr. Guthrie. Well, thanks.
    And Dr. Terry, I will get to you in a second on that. I 
have got a question.
    There was a new GAO report out Friday, and it finds that 
while some concerns persist--and a unanimous consent to enter 
this into the record.
    Mr. Pitts. Without objection, so ordered. \1\
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    \1\ The information has been retained in committee files and also 
is available at  http://docs.house.gov/meetings/IF/IF14/20150211/
102940/HHRG-114-IF14-20150211-SD006.pdf.
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    Mr. Guthrie. It said that CMS has done notable work to 
address concerns, providing educational tools, opportunities 
for testing, and Ms. Bocchino, is it your belief that resources 
and testing are available to those who want to be ready by 
October?
    Ms. Bocchino. Absolutely. And if I can make one other 
comment, they are providing all kinds of outreach and 
educational testing as well as end-to-end testing with claims 
and getting providers accustomed to the new.
    I also want to comment that running dual systems is just 
not feasible, even on the private-sector side. It is very 
costly, and what the plans are going to be doing on October 1st 
is they are going to be switching to new clinical policies and 
new algorithms based on the new codes, and having two tracks 
will just create more confusion for providers as well as for 
payers. It is important to send a very strong message that we 
are going to implement on October 1st.
    Mr. Guthrie. I want to talk to all the panelists, but I 
want Dr. Terry to go first, give you an opportunity. I married 
an Alabamian, so I appreciate your accent very well. My dear 
wife is from the Shoals.
    My question, well, there has been delays going on--well, 
first of all, I appreciate your concern because I know as 
things change in administration and health care and the 
Affordable Care Act, it seems to smaller individual or small 
personal practice, this is a bigger practice and a hospital has 
more administrative ability to cover their overhead, and we 
understand that. And also you have--Mr. Barton talked about 
it--I just switched to an iPhone. The reason I didn't for so 
long is because of the cost, time costs more than anything, but 
it was my decision because I was paying for it and my time just 
sit down and really learn how. I know how to use the 
BlackBerry. And so the difference was, it was really my 
decision because I was--although people in Medicare pay through 
payroll taxes, they pay through their taxes, they pay for their 
health care, but it goes through a third party. And so as we 
try to get information on what is being paid for, controlling 
costs of what is being paid for, that information is important 
to the people paying for it, which is really the taxpayer 
overall, so I understand your issues moving forward. And so the 
question is, with the GAO, the resources, I will start with Dr. 
Terry and all the others, we have had two delays 
administratively, one Congressionally. I mean, in the meantime, 
you see it coming, and what have you all been doing, people 
with practices that are smaller than hospitals or megapractices 
been doing to move forward knowing it is coming?
    Dr. Terry. Well, it has been entered into the record. We 
sent an attachment, the study that was done by an independent 
group a year ago that shows the costs that I quoted in my 
testimony, and that is true for my practice. We paid enormous 
costs to our computer people just to put the thing in. Some 
people have contracts and they don't have to pay the cost. We 
paid a lot of money, and if you send people off to--if you sent 
me off to a course to learn how to do it, that is more than 
$5,000 right there.
    Mr. Guthrie. Plus your time.
    Dr. Terry. So the cost--but we are not here to debate that, 
and we are not here to debate--I think to continue to delay it 
is not the right answer. Now, you are surprised I said that. 
You can delay, delay, delay but whenever that time certain date 
is, we are still not going to be ready, and it is because it is 
a flawed implementation. It is a big buying approach all in one 
day. The industry says it takes a year to get ready for this. 
How can you spend the time and effort and resources to prepare 
for something that is a year away when you don't know what it 
is going to do and then you don't even know when they turn the 
switch if it is going to work?
    We need a transition. The problem here is the 
implementation. Now, I can argue the product, why are using 
80,000 codes, the rest of the world 20. How can we compare data 
with the rest of the world when we have 80,000 codes and they 
have 20? How do those compare? But the problem here is the 
implementation, and it needs to be some kind of transition we 
have to figure out.
    Now, the dual system, I have heard CMS say they can't do 
it. I heard the Blue Cross Blue Shield man yesterday at the ICD 
coalition meeting say they are already doing it. So it can be 
done, and I don't know if that is the best thing to do, but we 
have to--physicians have to have a guarantee that we are going 
to get paid if we don't code right.
    Now, remember, why does coding have anything to do with how 
we get paid? We provide a service, and you are not going to pay 
me because I coded wrong? Everybody can't run a 4-minute mile. 
Some doctors aren't going to be able to do it, and do they 
deserve the death sentence and be put out of business?
    Mr. Guthrie. I understand your concern with that, I do. I 
appreciate it. Thank you.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from Oregon, Mr. Schrader, 5 minutes 
for questions.
    Mr. Schrader. Thank you, Mr. Chairman. I appreciate the 
opportunity. I appreciate the opportunity for the hearing.
    I guess, Dr. Burke, first question is, how many additional 
codes did you feel you had to deal with in your practice 
compared to ICD-9?
    Dr. Burke. Not many more. I would say maybe 10 or 20 
percent more.
    Mr. Schrader. OK. Then for Ms. Bowman, I guess, are there 
tables out there that would help private practitioners figure 
out what additional costs they are going to have to use? In 
other words, if you are a urologist, is there a set of codes 
you can handily go to or is this all done alphabetically and 
you have to figure out what code out of the list of 10,000 is 
going to fit your particular situation?
    Ms. Bowman. Well, the classification itself is organized by 
body system chapter, so the different specialties are typically 
organized together, and a lot of the medical specialty 
societies have developed cheat-sheet resources for their 
members on the codes typically used in that community.
    Mr. Schrader. So Dr. Terry, would you agree on this one 
point, anyway, that there is an ability to figure out what 
codes are relevant to your particular style of practice?
    Dr. Terry. Well, sure. One of the comments is that I am 
only going to have 50 or 60 codes as a urologist, but there are 
unintended consequences here, and Blue Cross Blue Shield of 
Alabama makes me code 10 diagnoses for every patient encounter, 
so I have a patient with a kidney stone, I can code that 
easily, but I have to code their diabetes, their coronary 
artery disease, their high blood pressure. Diabetes has 250 
codes, and if I don't do that, then Blue Cross--we are talking 
about Medicare and CMS, but guess what? We get paid by Blue 
Cross and United Health Care and Aetna, and it is going to kill 
me. I can't sit there and go through all those codes.
    Mr. Schrader. Ms. Bowman again, what do you see the role of 
ICD-10 versus ICD-9 in combating fraud and, you know, abuse of 
coding, if you will, that occasionally goes on by the very few 
practices?
    Ms. Bowman. For a lot of the same reasons that Dr. Hughes 
mentioned as the benefits of the specificity, it actually will 
help prevent and detect fraud, because right now there are so 
many services or diagnoses that are lumped into the same code, 
sometimes those that are covered and noncovered services are 
lumped into the same code. So as I often describe in some of my 
presentations, you can kind of hide behind the gray areas of 
ICD-9 whereas ICD-10, the specificity is such that it is black 
and white. The documentation should support what the 
specificity of that code is, and it should be much clearer, 
both to the provider in trying to assign the right code and the 
auditor or payer trying to determine that the correct code has 
been assigned.
    Mr. Schrader. OK. I guess, Ms. Bocchino, when they talk 
about cost, there seems to be disagreement. It is a relative 
level of costs that a practice or a hospital or provider would 
incur. There are different styles of practice, and medicine is 
changing. Even in my little veterinary medical world, our 
practice has changed dramatically in the last 35 years. Could 
you comment a little bit about the contrasting views we have 
heard today about the cost to the practice?
    Ms. Bocchino. I think a lot of it has to do with the 
contracts they have with vendors as actually Dr. Terry did 
mention, and if they are doing a lot of this internally and not 
using vendors externally, a lot of it is, do they have their 
own systems that they would have to go in and pay the cost of 
upgrading their own systems versus working with a particular 
vendor who is going to be responsible for all that upgrade, and 
it is just embedded in the contract. Also, some of the studies 
are more current now and so we have gotten more data on cost as 
more and more practices, particularly small practices, have 
begun the transition to ICD-10, and to comment on what Dr. 
Terry said before, right now some of the plans are using dual 
systems because some of the providers have converted over to 
ICD-10, but that has to stop because they are losing money on 
the additional costs that they have to put in to have both 
systems. This can't go on forever.
    Mr. Schrader. I guess, Dr. Terry, last question for me 
anyway would be, you know, the system is changing. It used to 
be--I was a veterinarian. I just provided a service and I knew 
I was doing a good job. My patients got better. My clients were 
satisfied at the end of the day. But medicine in general seems 
to be moving to a more value-based outcome system. It is very 
different than my fee-for-service system. And frankly, we are 
asking the Government and the taxpayer to fund a lot of this 
stuff.
    So what is your thinking on, you know, the evolution of 
medicine here? I mean, you and I are a little older than some 
of the young bucks coming up these days, and they are going to 
the computer to figure out what the diagnosis is and stuff as 
much as relying on their own instincts. How does the movement 
to value-based medicine affect our view of this coding system?
    Dr. Terry. Well, you are right, I am a dinosaur but I know 
how to turn on a computer.
    Mr. Schrader. I do too.
    Dr. Terry. You just opened up a whole other can of worms, 
what I think bout value-based payment. We don't even know how 
to define value, OK, so how can you pay for value when we can't 
even define it? You know how as a patient if my treatment is 
valuable but how is the Government going to define it? I am not 
going to go there, but that is the problem with it.
    You know, they talk about these statistics but, you know, 
in medicine, we have something called the scientific method, 
and it is not statistics. These codes are for statistics, not 
for research. Now, you can do statistical research but you 
can't do medical research. It is not the scientific method. So 
I have concerns about some of the amendments and argue of the 
benefits of all of this.
    Mr. Schrader. Thank you, and I yield back.
    Mr. Pitts. The Chair thanks the gentleman and recognizes 
Dr. Burgess, 5 minutes for questions.
    Mr. Burgess. Thank you, Mr. Chairman, and again, I thank 
you for holding the hearing. A busy morning, several things 
going on, so I apologize for my absence through part of this. 
If there is a question I ask that has already been asked, I ask 
that you be indulgent and not point that out to me.
    On the issue of value-based services and pay-for-
performance, I mean, Dr. Terry, I just have to tell you, there 
was never a morning when I drove to work in my OB/Gyn practice 
in Louisville, Texas, where I thought to myself, boy, I really 
hope I can be average today. You go to do your best work every 
single day. That is why you show up. That is why you are there 
for your patients, and I am a little troubled as is Dr. Terry 
about the fact that we are talking about a system that 
basically revolves around reimbursement and not so much the 
deliverable to the patient which, after all, at the end of the 
day is where we should be concerned.
    But the concept has been discussed about having a dual 
system. Dr. Terry, do I understand you correctly that you would 
see perhaps value in running both systems simultaneously for a 
while after October 1st?
    Dr. Terry. I am not an expert on that but the value is that 
it is a way to transition. It is a way to let doctors get that 
year of experience and learn how to do the coding so that they 
don't--when we turn the switch and they are not ready to do it 
that their income doesn't go to zero, so that is the value. 
Now, whether that is the way to do it or not, there may be 
other ways to do it.
    Mr. Burgess. Well, it is interesting that you bring that 
up, because if you go to the CMS Web site, and I don't spend a 
lot of time but when I do go, I do go to the Frequently Asked 
Questions section and there is an item that says dual coding, 
does my practice need to use both code sets during the 
transition, and the answer is, practice management systems must 
be able to accommodate both ICD-9 and ICD-10 codes until all 
claims and other transactions for services prior to the 
compliance date have been processed and completed. Well, that 
is CMS jargon for ``we are not giving you a date.'' So, you 
know, under their own information on the Web site, maybe the 
problem is solved.
    You know, you go to other areas on their Web site and you 
try to click on the video for how you do this in your own 
office, and you are taken to an outside Web site that you need 
a username and a password, so you develop a username and a 
password, you click on it again, and the site is broken. So I 
mean, there are some real obstacles that you as a practicing 
physician when you try to do your due diligence and make sure 
everything is going to go smoothly, there are some obstacles 
put in your way.
    Ms. Matus, your provocative statement to us, and I would 
love to go--but the chairman has already done it so I won't put 
the committee through it again, but pull the plug or pull the 
trigger. I mean, I would just love to go down the line and say 
trigger or plug, but I think I know what your answers are.
    But even at--and I do want to say, your CEO came to talk to 
one of our roundtables and provided one of the most refreshing 
views of ways to go forward with things that I have ever heard, 
so a lot of respect and affection for your CEO at Athena 
Health, but even on your own Web site, the Frequently Asked 
Questions on the Athena Health Web site, number 7, ``How can 
the transition to ICD-10 impact my cash flow.'' The answer here 
is instructive. It says ``CMS estimates that in the early 
stages of implementation, denial rates will rise by 100 to 200 
percent and the days in accounts receivable will grow by 20 to 
40 percent.'' Those are pretty significant figures, and I will 
just tell you from having run a small practice that you extend 
my days in AR by 20 to 40 percent and I am probably having to 
go downtown and ask my friendly banker for a short-term loan at 
a high percentage interest rate in order to keep my practice 
afloat. Is that a fair concern of the practicing physician out 
there?
    Ms. Matus. I think I am going to add on what Ms. Bocchino 
said. It depends on what software provider you use. As I 
mentioned, we do guarantee ICD-10 performance, and part of the 
reason that we can do that is, we have one completely Internet-
based system. So if we, for example, have a claim rejected for 
one provider, we can go out overnight and make sure that any 
other claims that are in queue that look similar to that are 
changed so that they will go through appropriately the next 
day. So I think, you know, again, it depends on what system you 
are using and how you are formatted, but there are ways to make 
this easy to do, and when you think about ultimately--when you 
heard John, we are so focused on building the healthcare 
Internet, and to be able to do something like that, you need 
one language. If you think about how we live our lives today, 
we have one system for financial information, we have one--you 
know, all our information, all our music is on our phones yet 
our health care--I have lived in six States, 10 years in the 
great State of Texas, my healthcare information is scattered to 
the winds. So this is really important I think long term for 
foundationally building a healthcare system that is integrated.
    Mr. Burgess. Right, but for those practices that did not 
have the foresight and intuition to align themselves with your 
organization----
    Ms. Matus. There is still time.
    Mr. Burgess [continuing]. They may be in difficulty.
    Mr. Chairman, I do want to submit for the record a series 
of questions by Daniel Chambers, who is the Executive Director 
of Key Whitman Eye Center in Pete Sessions' district back in 
Texas, and I just want to point out one of the things that he 
says there is that physician offices may need to be prepared to 
go out and cover this delay in accounts receivable for an 
extended period of time, and under existing tax law, we are in 
our practices are not allowed to carry over money in our 
practices or it is taxed and then we are going to pay taxes on 
it twice. So this is an untenable situation that a lot of 
practices find themselves in.
    Mr. Chairman, I thank you for the indulgence. I do want to 
submit this for the record.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from California, Mr. Cardenas, 5 
minutes for questions.
    Mr. Cardenas. Thank you very much, Mr. Chairman.
    I would like to thank all the witnesses for apprising us of 
the perspective that you bring and thank you for representing 
all the constituency interests that are so important to the 
health care of all of our constituents throughout the country. 
Thank you very much.
    My first question is to Mr. Averill. I understand that 
there are concerns that increased number of codes may be a 
burden for physicians, and I am glad you testified on some of 
those reasons earlier regarding the switch to ICD-10 and how it 
would in fact be an excessive burden for some practitioners. 
You recommended specifically that no individual would need to 
know all the codes obviously, just like was mentioned 
smartphones. This thing seems to be smarter than me. There are 
things that thing does that I don't even know where to start.
    I would imagine that with today's technology looking up 
codes by doing a word search, for example, would be very simple 
and wouldn't hinge much on how many codes are available, again 
not having to know everything but just being able to utilize it 
accurately and effectively is what I think every practical 
system is expected to do.
    I have a question. Would it be--would I be right to assume 
that modern technology makes more comprehensive coding systems 
like ICD-10 manageable?
    Mr. Averill. Yes, they do, and since the iPhone has gotten 
quite a bit of visibility today, there is an app for I-10. It 
is a free app, and you can look up an iden code. If you wanted 
to really splurge, there is one for $1.99 that will give you a 
few bells and whistles on your iPhone to look up a code, and if 
you take that technology, in a few seconds you could look up 
almost any I-10 code.
    Mr. Cardenas. OK. So the technology of today makes it much 
less burdensome than the implementation of years past, correct?
    Mr. Averill. Correct.
    Mr. Cardenas. Mr. Chairman, for the record, before I run 
out of time, I would ask to submit, the California Hospital 
Association asked me to submit a letter to the hearing record 
that states they are ready for the announced October 1st, 2015, 
ICD-10 compliance date and urges Congress to avoid any further 
delays, and I would like to submit that letter for the record, 
Mr. Chairman.
    Mr. Pitts. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Cardenas. Thank you so much.
    Carmella Bocchino, did I say your name right? Thank you. I 
have heard the argument that given that the World Health 
Organization will be implementing ICD-11 in 2017, the United 
States should just wait to implement that coding system. I also 
understand that there is an argument that implementing ICD-10 
makes it easier to eventually implement ICD-11 down the road. 
My question is, would skipping straight to ICD-11 be 
counterproductive, or what is your opinion on that?
    Ms. Bocchino. Our opinion is no, it would be 
counterproductive in that----
    Mr. Cardenas. How so?
    Ms. Bocchino. ICD-10 builds off of ICD-9, and there has 
been a lot of resources and training and effort gone into many, 
many people in the healthcare system, not just payers, to get 
us to ICD-10, and you end up penalizing them for all the 
resources that they put forward already if you are now going to 
make the jump and continue to use what I think is an antiquated 
system in ICD-9.
    Mr. Cardenas. One of the arguments again, Ms. Bocchino, one 
of the arguments in any change is come on, we are looking at 
this with a broad brush. It doesn't necessarily help the 
individual constituent or the individual patient in this case, 
but one of the things that I believe that this system makes 
sense and the fact that the whole world or at least most of the 
world seems to want to comply and is doing what they can to do 
so. I think the United States should follow suit.
    Doesn't it, at the end of the day, come down to the 
individual knowing more about what diseases are going on and 
going around now that the world is getting smaller every day?
    Ms. Bocchino. Absolutely.
    Mr. Cardenas. At the end of the day, doesn't it directly 
affect the individual patient?
    Ms. Bocchino. It does. It affects the individual patient 
both in the sense of us knowing a lot more about complication 
rates, about a lot of the research that actually Dr. Hughes 
raised up, which is going to drive better patient care and 
engage patients to better take care of themselves.
    Mr. Cardenas. Isn't it today more than ever doctors 
communicate with each other telephonically, electronically? My 
understanding, I just had somebody--I helped somebody put 
somebody in touch with a doctor who lives in northern 
California, the patient was in my district, and lo and behold, 
within 24 hours that specialist was looking electronically at 
some information so that he could give that second opinion 
where that patient was in the hospital, couldn't physically go 
see that doctor, but yet again, my point is that communication, 
that is happening more and more today, and that is a good 
thing, right?
    Ms. Bocchino. It is, and it is happening a lot more in 
rural areas where we don't have a lot of specialization and you 
need exactly that kind of connectivity.
    Mr. Cardenas. Thank you very much, Mr. Chairman. I exceeded 
my time. Thank you.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from Virginia, Mr. Griffith, 5 minutes 
for questions.
    Mr. Griffith. Thank you, Mr. Chairman, and I appreciate 
that very much. I appreciate the witnesses being here today.
    Dr. Terry, if you could help me out on this, I know we 
apparently got smartphones and all kinds of computer programs 
that will help you with the ICD-10, but they also come out in 
book form, do they not, the ICD-9 and the ICD-10? And my 
understanding is, the ICD-9 is about one volume about yea 
thick. Is that right? If you can answer for the record?
    Dr. Terry. Yes, about 2 or 3 inches.
    Mr. Griffith. And that the ICD-10 would be about four of 
those same size books. Is that about right?
    Dr. Terry. I have not seen it but it makes sense.
    Mr. Griffith. All right. And you indicated earlier that the 
rest of the world is using 20,000 codes but that we are about 
to use 80,000 codes, but then I heard testimony that the World 
Health Organization is coming out with an ICD-11. Is most of 
the world using the ICD-10 already or is that just 
aspirational?
    Dr. Terry. Yes, the rest of the world is using ICD-10, but 
it is like you are comparing apples and oranges. The rest of 
the world is using less than 20,000 codes and they don't use it 
for billing, they don't use it in the outpatient setting. But 
you are saying oh, we have to keep up with the rest of the 
world but we are doing it totally different.
    Mr. Griffith. OK. So if we do it the rest of the world did 
it, then you would be OK with it, or you could at least figure 
it out. Is that a fair statement?
    Dr. Terry. Yes, sir.
    Mr. Griffith. And you said something about how many codes 
there were for diabetes, and I failed to write that down. How 
many different codes are there for diabetes?
    Dr. Terry. Two hundred and fifty.
    Mr. Griffith. Two hundred and fifty codes. I guess my 
problem with the ICD-10 and this whole concept, and it comes 
down to part of what you are saying. It would seem to me to 
make sense that you could do a dual system. Now, ultimately, 
you want to get everybody on ICD-10. I get that. But if you 
submitted for a period of years ICD-9 and ICD-10 and if you got 
either one of them right, you got paid, then that would 
probably alleviate your fear and concern. Is that correct?
    Dr. Terry. My fear is just being able to take care of the 
patient and not being put of business because I code wrong. 
That is my fear, and how you can fix that? Like I said, there 
are several ways to do it.
    Mr. Griffith. And do you know what the projections are on 
the numbers of the shortage of doctors that we are anticipating 
having in this country?
    Dr. Terry. I don't know numbers but it is definite. I mean, 
there are fewer people wanting to go into the practice of 
medicine because of the financial aspects, and it is just----
    Mr. Griffith. And lots of paperwork and dealing with lots 
of computers instead of seeing patients. Is that right?
    Dr. Terry. You are talking about computers and statistics, 
but one thing hasn't changed, and that is the care of the 
patient, the sitting down and listening and examining and 
talking. Computers can't do that. And I don't have time to do 
that anymore. I am sitting in my office with my back to the 
patient typing on my computer trying to take care of my 
patient, and if you have a 15-minute office visit, that is 
getting whittled down by 50 percent now, and it is not all ICD-
10. It is Meaningful Use, electronic medical records. It is 
trying to learn how to deal with this, but ICD-10 is going to 
pile on it.
    Mr. Griffith. And as a result of that, it wouldn't surprise 
you that either last year or the year before that, I sat down 
with a doctor in one of my rural communities that I represent 
and his number one complaint was ICD-10, and he said look, I am 
getting old, I am not a dinosaur but I am getting old, or 
older, and I love serving this community but I don't know if I 
am going to continue to practice.
    So you would anticipate that pushing with a drop-dead date, 
as Dr. Burgess pointed you earlier, the dual coding is only 
going to happen up to a certain date, not allowing for things 
to go forward after that. You think like him that there would 
be a lot of other doctors that may decide that it is just time 
to go ahead and retire and enjoy their house at the lake?
    Dr. Terry. There is no question. I already have a doctor in 
Mobile that has already quit because of the thread of ICD-10 
plus he didn't want to have to take his boards a fifth time, 
and there are a lot of people--you know, I am 60, 61, you know, 
there are a lot of people between age 61 and 65, they are not 
going to do it. Now, how do you measure that? I am just telling 
you it is going to happen.
    Mr. Griffith. So what we are going to see is that my 
allergist, who served my family for five generations and who 
didn't stop practicing until 1992, and even though his body was 
getting weaker all the time, his eyes flashed and he always 
knew what was going on, you are indicating to me that we are 
not going to have those doctors continue into practice as long 
and that that is going to create a problem in our rural 
communities, notwithstanding the fact that some of the younger 
doctors like Dr. Burke will figure it out, but it is going to 
create a shortage of doctors, particularly in the rural areas. 
Am I correct that that is part of what you are saying here 
today?
    Dr. Terry. Yes, sir, but it doesn't have to be that way if 
we can change the ways being implemented. It doesn't have to be 
that way.
    Mr. Griffith. Well, I appreciate you being here very much. 
I appreciate everybody else, and I understand for big practices 
and big cities, all of this is easy, but it is not so in the 
rural areas where we are already having healthcare shortages.
    Thank you. I yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes Mr. Long from Missouri, 5 minutes for questions.
    Mr. Long. Thank you, Mr. Chairman, and thank you all for 
being here today.
    When I was elected in 2010, and we came up for orientation 
that next week, there was 96 new Congressmen out of 435, and we 
were all excited, and they gave us our little briefcase with 
things in it, documents, everything we need, and they gave me a 
BlackBerry, and I said, ``What is that?'' They said, ``Everyone 
gets a BlackBerry.'' I said, ``I don't get a BlackBerry.'' They 
said, ``Why not?'' I said, ``I have never had one, I don't know 
how to use one.'' I get an iPhone. ``No, no, no, we don't get 
iPhones, you get the Government issue, you get a BlackBerry.'' 
I said, ``I don't want it, I can't use a BlackBerry, I don't 
want to relearn a BlackBerry.'' So I was the first Congressman 
that changed the policy here, so I hold the record. I was a 55-
year-old freshman at that time. I was a 55-year-old 
trendsetter. So I got my Government-issued iPhone, and now they 
give them to everybody. I know it is a little off the subject, 
but that is what all the discussion was on iPhones or 
BlackBerrys here this morning.
    And Dr. Terry, you do the best impersonation I have ever 
seen of my doctor in Springfield, Missouri. I should say my 
former doctor, because when Obamacare first passed, I went to 
see him, and you remind me of him because I told him, I said if 
you don't settle down, I am going to have to check your blood 
pressure. He turned around to the computer and he was working 
just like you imitated a minute ago, and he said I have got to 
do all this paperwork now. He said I have got 10 hours a week 
just on new things. He said it used to be I would send you out 
of here and now you have to sit there and answer these 
questions for me, and he quit about 6 months after that, and he 
was in the same age bracket as you and I, and he had several 
good years left in him. So I know that this is very 
disconcerting for a lot of doctors.
    And for my friend from my State of Missouri, and you are 
from where in Missouri?
    Dr. Burke. Fredericktown.
    Mr. Long. Fredericktown. My mom's people originally came 
from Fredericktown, so we have got a little in common there.
    You said--I don't guess you said it, but there are supposed 
to be significant public health benefits to the greater coding 
and reporting under ICD-10. Will you kind of discuss some of 
those benefits?
    Dr. Burke. I mean, you know, for instance, if, you know, 
someone comes in with COPD, or emphysema, you would put the 
code in, and it can talk about an acute exacerbation or chronic 
COPD, unspecified. So it gives us a clearer picture of what is 
going on with the patient.
    Mr. Long. OK. And I have heard of both of those, but the 
ICD-10 diagnosis codes have been readily mocked for their more 
obscure codes. For example, there is a code--I don't know if 
you run into this--but in our neck of the words down in 
Missouri, you might need this one: bitten by a pig, initial 
encounter. And walked into lamppost, subsequent encounter.
    Mr. Griffith. What about a subsequent encounter with the 
pig?
    Mr. Long. Maybe that is why he ran into the lamppost. A pig 
bit him, and he ran into the lamppost. Isn't this overwhelming 
for small solo practices in rural America like your represent, 
not that you have a sole practice, but I mean, you are out 
there in a town of 4,000 people.
    Dr. Burke. Yes, true. I don't think it's overwhelming. I 
think it is easier to find a diagnosis because you have a lot 
more choices for the diagnosis.
    Mr. Long. I would say you do if you have got ``bitten by a 
pig.''
    Dr. Burke. So, you know, I think it is--I just don't think 
it is overwhelming, not at all, not in the slightest bit. You 
know, for the scope of my practice, which is internal medicine, 
and actually our software is the one that helps us out because, 
for instance, if someone comes in with a complaint and there is 
an ICD-9 code in the chart, we can click on the ICD-9 code and 
then a bunch of different ICD-10 codes can show up, and we can 
go through the list and pick one which is more specific.
    Mr. Long. OK. You said in your opening remarks that it 
was--I am paraphrasing but kind of like a light switch. You 
switch one day from 9 to 10 seamless, no problem whatsoever. 
Dr. Terry in his answer to a question earlier I believe said 
that it would take $5,000 in training to get somebody up to 
speed. Did you have to undergo any special training or spend 
any money or go off somewhere to learn this, or----
    Dr. Burke. No, I didn't, and neither did the nurse 
practitioners, so no one in our office did.
    Mr. Long. OK. And Ms. Bocchino, healthcare communities have 
had years to plan for ICD-10, including several delays. Have 
the insurers used this time to prepare?
    Ms. Bocchino. Absolutely, and they have worked with the 
providers in their network to do end-to-end testing in 
providers of all size, so they have done a lot of outreach, 
even to the smaller providers. I will be honest that it is 
difficult sometimes to get the smaller providers engaged, but 
in part that is because many providers believe that we are 
going to keep moving the date, and until we are firm on a 
particular date that they know this is coming, I don't think we 
are going to get some of them engaged. I think it is very 
important to send a strong message.
    Mr. Long. OK. Thank you. I downloaded a couple of apps here 
on my iPhone on ICD-10 after we were advised earlier, but you 
said a dollar. Now, the first one that came up was $4.99 but I 
did find some free ones, so I have got two apps. Now I can go 
study and see what is in there besides first encounter bitten 
by a pig, and I yield back.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the ranking member of the full committee, Mr. 
Pallone, 5 minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman. I feel like old times 
up here today. This is nice. And I apologize. I was at one of 
the other subcommittees earlier, so this is why I missed your 
testimony.
    But I wanted to ask Ms. Bowman, or Mrs. Bowman, I guess, 
you mentioned in your testimony that the demand for high-
quality data is increasing due to healthcare initiatives that 
aim to improve quality and patient safety while decreasing 
cost. Can you explain how ICD-10 will interact with the 
electronic health records Meaningful Use incentive program, and 
what about other delivery system reform efforts?
    Ms. Bowman. Sure. The ICD-10 codes in addition to being 
used directly for reimbursement like we have heard a lot about 
today is also used for a lot of administrative data reporting 
purposes where aggregation of data is important. So it helps to 
provide data for all these other programs like value-based 
purchasing, accountable care organizations to show the severity 
levels of different conditions so that you can link that to 
outcomes to best practices, to different treatment options and 
see really what works, what doesn't work, what is the most 
cost-effective form of treatment. If you have better 
information about what is really going on with the patient and 
the level of severity of a particular illness, not just a 
generic description for that illness, you can fine-tune that 
information a lot better and really drill down to what works 
and what doesn't work.
    Mr. Pallone. OK. Now, you also mentioned that the updated 
ICD-10 codes would help with reimbursement. Would you want to 
explain how it would ensure more accurate and fair 
reimbursement or more accurate codes would reduce providers' or 
payers' administrative burden, for example, in clarifying 
diagnosis and procedures?
    Ms. Bowman. Sure. Because of the increased specificity, you 
can drill down to different forms for the same reason. They 
kind of give you better information on the different costs 
related to particular diagnoses and procedures. A great 
procedure example that I think Rich might have used in his 
testimony but I heard it before is, suture of artery. So we 
have a single code that is a procedure example, and it doesn't 
matter whether it is the aorta or an artery in your little 
finger. It is the same code in ICD-9, and obviously there is 
enormous differences in complications and the cost of repairing 
the aorta versus other types of arteries and yet we are lumping 
it all into the same code. So by having better specificity on 
the procedure side, a lot of it has to do with approaches, 
anatomic sites on both the diagnosis and the procedure side. We 
can really be able to fine-tune information about the cost of 
treatment, which then links to the appropriate reimbursement 
for that treatment.
    Mr. Pallone. And you mentioned about the cost and danger of 
continuing to use the ICD-9 codes. Who are those costs 
affecting?
    Ms. Bowman. These costs are affecting everyone, our entire 
healthcare system, providers, payers, the patients because 
right now because we don't have that specific information and 
ICD-9 is just deteriorating and failing more year after year 
that we use it. We are getting less and less information for 
each clinical encounter, and basically reimbursement, analyzing 
quality of care based on that data are just wild guesses at 
this point because there are so many disparate conditions or 
procedures that are lumped into a single code, and in some 
cases some of the testifiers had talked about differences in 
ICD-10. Some of those differences have to do with just changes 
in clinical knowledge since ICD-9 was developed. So some 
conditions are actually categorized somewhat differently. I 
believe there is even some medical conditions that are not 
categorized as cancer in ICD-9 but are categorized as cancer in 
ICD-10 because of changes in medical knowledge. So we are 
losing a lot of that information by continuing to use ICD-9.
    Mr. Pallone. OK. And then lastly, some providers argue that 
ICD-10 is unfair because it was developed by bureaucrats that 
have never practiced medicine, but you mentioned in your 
testimony that 95 percent of the requests for new codes in the 
past few years came from physician organizations. Can you just 
talk a little bit about how i10 was developed and who was 
involved?
    Ms. Bowman. Sure, and that has been one of the biggest 
myths, I think, of ICD-10 is that it was developed in a back 
closet somewhere by bureaucrats. I have actually been involved 
in the development of ICD-10 since the 1990s now, and it is 
still being updated and maintained every year, and all of the 
content of the original ICD-10 that WHO uses, the clinical 
modification that the United States is trying to implement, all 
of it was contributed to greatly by the house of medicine who 
participated in the development, asked for that clinical data 
and continue today to come to public meetings that are hosted 
by the CMS and CDC to discuss proposals for new codes, and it 
is a completely public process. Anyone can submit a request for 
a new code. It is discussed in a public meeting. There are 
opportunities for public comments at the meeting or in writing 
afterwards, and CMS and CDC take all of those comments into 
consideration in making a final decision about adding new 
codes.
    Mr. Pallone. Thank you.
    Mr. Pitts. The Chair thanks the gentleman and now 
recognizes the gentleman from Indiana, Dr. Bucshon, 5 minutes 
for questions.
    Mr. Bucshon. Thank you very much, Mr. Chairman.
    I was a practicing cardiovascular surgeon for 15 years, so 
at the end of the day this is about money. This is going to 
cost physician practices initially, and I agree with Dr. Terry 
on the implementation. It is pretty clear that we are going to 
move forward on ICD-10, and we should, but I do have 
substantial concerns about the implementation and the short-
term impact on physician practices because that will happen, 
and I am disappointed that some of the experts in non-
healthcare fields that don't practice medicine are here today 
denying that will happen. That is very disappointing.
    Ms. Bowman, have you ever practiced medicine? Have you ever 
had to bill a patient?
    Ms. Bowman. No, I have not practiced medicine.
    Mr. Bucshon. Let me tell you what is going to happen, and I 
am going to--because you--and again, ICD-10 is going to happen. 
It needs an implementation plan. I agree with that. I don't 
think we have a disagreement there, but that said, here is what 
happens when you are a surgeon. You will do surgery, and it 
will be much more difficult for you or your people to find a 
code that matches what you write on your operative report. You 
know why? Because you are going to be in the operating room and 
you are going to dictate what you actually did. You are not 
going to look through an ICD code book and make sure it 
matches. And so when the insurance company gets the code and 
they get the operative report, they are not going to match, and 
it is going to come back to your office and you are going to 
have to try to figure out, and then what do you do? Do you 
modify part of the official hospital record and say no, that is 
not--I had to change it to match a code? You could do that. But 
it will not make it more easy to get the correct code. From a 
practicing physician, my opinion, that is just false. That 
won't happen. So I am concerned about that.
    Dr. Burke, is your practice independent or are you part of 
a larger healthcare system?
    Dr. Burke. There are two physicians and three nurse 
practitioners, and I am----
    Mr. Bucshon. So you are not part of a larger conglomerate 
that owns your practice?
    Dr. Burke. No, privately owned.
    Mr. Bucshon. OK. That is good because it is a rarity that 
that is happening today, and the reason is, is because the cost 
to run an individual medical practice is very difficult. I was 
in a 15-surgeon, 16 cardiology practice. We had to sell to the 
hospital. We couldn't afford to stay independent anymore.
    But I was interested in your cost statement, that it didn't 
cost anything. What are your annual IT costs? What is your--how 
much do you pay a month for your IT service?
    Dr. Burke. I would have to talk to the office manager about 
that.
    Mr. Bucshon. My point is, you made a statement that said 
the cost is zero, and that is just false because you are making 
monthly or annual payments to your IT and this type of 
implementation is included in that cost.
    We put an EMR in in 2005 in my practice. It cost us $3 
million up front, $60,000 to $80,000 a year just to maintain 
the current software. This is extremely expensive for medical 
practices. It may not be that, you know, oh, converting from 
ICD one day to the next cost you anything, but it is costly, 
and I think that that is something I want to clear up because I 
think that is just not accurate.
    Ms. Matus, do you know what percentage of the healthcare 
costs are related to physician services?
    Ms. Matus. I don't know specifically.
    Mr. Bucshon. People estimate about 10 to 15 percent. Where 
is the rest of the cost to the American people for health care?
    Ms. Matus. I would imagine it is in administrative.
    Mr. Bucshon. Yes, about 25 percent is in administrative and 
then, you know, there is hospital expenses and others, right?
    So, you know, the reality is, is that trying to continue to 
save Medicare or save our system by cutting reimbursement to 
providers is a failed strategy, and this is what this is about 
because what is going to happen is, is you are going to have 
physicians who are not going to be able to code this properly 
at all age groups except if they work for you, which it is 
great that you have a great system, but the individual 
physician out there is not going to be able to do this 
correctly, and their AR is going to go dramatically up and they 
are going to get denied, and it is not just for Medicare. It is 
going to be from every other private insurance company out 
there.
    So I would encourage all of us who are involved in health 
care including on the administrative side to really look 
closely at our implementation plan and make sure that we can 
implement ICD-10, which we need to, in a way that does not 
really cause dramatic problems with our healthcare system.
    My practice, you know, we could afford to have a line of 
credit of $1 million. With this kind of thing, we could front 
it for a few months. Many practices can't.
    And lastly, Dr. Hughes, the example that you gave of a 74-
year-old with a vascular injury, I did vascular surgery. Other 
than for your research and for statistics, how does that impact 
that patient's medical care? Because given your example, it has 
no impact on the outcome of that patient, not a single--nothing 
that----
    Dr. Hughes. I am sorry if I gave you the impression that 
that individual patient would be affected because you are 
absolutely right, it is not going to have any impact.
    Mr. Bucshon. It won't make any difference.
    Dr. Hughes. It won't make any difference to that individual 
patient. The point I was trying to make is that the 
accumulation of data is useful, and I disagree with Dr. Terry. 
I do believe that it is possible to look at data in a 
scientifically sound method and to derive useful information 
from it. We have got lots of information from the National 
Surgical Quality Improvement Program, for example, but you are 
absolutely right. It is not going to make any difference to----
    Mr. Bucshon. I just wanted to clear that up that in the 
short run, implementation of ICD-10--and thanks for your 
indulgence for a second, Mr. Chairman--will not have a direct 
impact on the individual patient care. It may in the long run 
based on your research, which I agree.
    Thank you, Mr. Chairman. I yield back.
    Mr. Pitts. The Chair thanks the gentleman and now recognize 
the gentleman from New York, Mr. Collins, 5 minutes for 
questions.
    Mr. Collins. Thank you, Mr. Chairman. Sorry I was somewhat 
late. I was actually here on time, but I serve on Oversight. We 
were just ending a hearing on mental health, which I wanted to 
stay until it was over. So I missed most of the testimony 
although I did review the information, and just to set the 
stage, I am a supporter of ICD-10. I am a supporter of getting 
it implemented sooner than later. It has been on the agenda a 
long time. This isn't something that should be new to anyone. 
Most countries in the world are doing it. I certainly have a 
lot of physician friends, and I understand there is a cost of 
implementing anything new. You know, we can, I suppose, debate 
the benefits.
    I am also a data guy. In my office I actually do have a 
sign that says ``In God we trust. All others bring data.'' And 
I know that with data, whether it is analysis or other things 
we can do with it, while it may not be a positive for that 
patient today, at some point in time being able to deep-dive 
data, especially with healthcare costs going up in this country 
as they are, someone of my son's young age will be able to 
really use that data. He is very adept at that.
    So I guess my question is--and feel free--I am sorry, I 
don't know who would be best at answering some of these, but I 
would see the data collection as a very major part of why we 
are doing it and maybe perhaps the other piece--I don't know if 
this came out--some identification of potential, I will use the 
word ``fraud.'' You know, the more data we have, the more 
specific someone has to be, and if someone could comment too, I 
would assume a lot of the coding will be done by the office 
staff. I mean, a dermatologist is going to be rocking and 
rolling. Her staff knows that I would think a lot of the coding 
would be coming from that. Is that a good assumption or bad, 
and could anyone speak to where this data would be helpful in 
the medical field going down the road?
    Ms. Bowman. Yes, you are absolutely right. The data is very 
useful and helpful, and the fraud arena is one example, and the 
research that Dr. Hughes mentioned, yes, in most cases it is 
not necessarily going to help that patient today but the 
accumulation of data and knowledge about medical care will 
ultimately lead to better care for patients in the future.
    There are some scenarios where it could help the individual 
patient today such as in the area of disease management. I know 
of some facilities now that are using the better diagnosis 
codes in their internal systems for disease management 
programs, particularly in the area of diabetes and asthma, 
because the clinical classification of asthma in ICD-10 is 
totally different than ICD-9 and is much more aligned to the 
way people are currently managing asthma, so I know of some 
facilities that are using the data that way.
    With respect to the coding, obviously in hospitals almost 
all of the coding is done by professional coders who do the 
coding. In large practices, it usually is designated staff, and 
so there is a cost to the practice obviously, even in those 
situations of having the staff trained, and then in some 
smaller practices such as the Beyer Medical Group that is here 
today, it might be physicians who are actually doing their own 
coding but in a lot of scenarios it is usually a trained staff 
person.
    Mr. Collins. So this has been implemented, am I correct, in 
other countries?
    Ms. Bowman. Yes.
    Mr. Collins. What have we learned--and we have only got a 
minute or so--the benefits of this has been evidenced by other 
countries having already implemented it?
    Ms. Bowman. Well, Dr. Terry, I think it was, in his 
comments is absolutely correct. Other countries are not using 
it in the same way that we use it, and that is kind of a catch-
22. That also makes it more complicated for us to implement it 
because of the fact that we do use it in our reimbursement 
system. So they didn't have some of the challenges and the 
costs and the issues that we are facing.
    There was a comment earlier about not being comparable 
globally. However, we have a treaty with the World Health 
Organization for ICD. The modifications individual countries 
can make to ICD have to be beyond a certain character level in 
order to be able to maintain global comparability, and as I had 
mentioned in my testimony, almost half, actually 46 percent, of 
the additional codes in our modification are due to laterality, 
which is not in the international system, primarily because 
although they are actually oddly enough looking at that in the 
area of ICD-11. They are actually looking at what we did in our 
clinical modification as they work on ICD-11.
    So there is comparability with the rest of the world 
because a lot of the detail, it has to do with ways we use the 
codes in our country that just aren't applicable to the rest of 
the world, the laterality and also there was significant 
request for--I know there was jokes about the subsequent 
encounter and initial encounter but those kinds of things, 
which are all in the seventh character, are where some of those 
additional codes come, and it is actually intended to improve 
our data from ICD-9, which right now if you have a follow-up 
encounter, it goes into a very generic aftercare code, which 
has been a big complaint for 30 years in the ICD-9 system that 
I can't tell that the reason I am seeing the patient was 
because they are being followed up for a fracture of the 
humerus. All I know is, it is orthopedic aftercare or a follow-
up examination for who knows what.
    So these encounter seventh characters were specifically 
created to solve that problem in ICD-10 so that it is an added 
digit to say you still use the original injury code but you 
know from this particular character that it is a follow-up 
visit and not the initial acute injury.
    Mr. Collins. Thank you, Mr. Chairman. I yield back.
    Mr. Pitts. Thank you. The Chair now recognizes the 
gentlelady from North Carolina, Mrs. Ellmers, 5 minutes for 
questions.
    Mrs. Ellmers. Thank you, Mr. Chairman, and thank you to our 
panel for being here, and I too apologize for coming in late, 
so if any of the questions that I ask have already been 
answered, again, I just apologize. I am trying to get to the 
bottom of this issue.
    First, I would just like to say I am a nurse myself. I 
practiced before coming to Congress as a nurse for over 21 
years. My husband is a practicing general surgeon, and I will 
just have to say that my husband's opinion of moving towards 
ICD-10 is very much like Dr. Bucshon and Dr. Terry, although we 
know that this needs to be implemented at some point. I believe 
the frustration that exists within our medical community, 
especially our private practitioners, is that there is so much 
on top of them right now dealing with so much that now this is 
just one more issue that they are going to be forced to deal 
with. Many of our physicians and hospitals alike are still 
trying to meet stage II of Meaningful Use, and here we have yet 
another situation where we are going to have to deal with this.
    So I want to get to the bottom of this. I want to see ICD-
10 move forward but obviously we have to address the issues as 
they are in the realistic world rather than the theoretical 
world where this would be a wonderful thing as implemented. We 
just have to get there and apply it to the realistic world of 
health care and medicine as it is today.
    So one of the big issues that we here continuously is, 
again, the cost, and the cost--you know, we know that our 
hospitals have invested millions in preparing for ICD-10, and I 
believe that that needs to be respected and we need to consider 
that for our physician practices, especially--and I know, Dr. 
Burke, you are practicing in a rural area--especially for our 
rural physicians and some of our smaller practices.
    Dr. Averill, what can be utilized? Is there a cost 
incentive for physicians to embrace ICD-10 that you are aware 
of?
    Mr. Averill. Well, first of all, let me say on the cost--
there was just a recent study that was just released in which 
PAHCOM, which is the office managers for small physicians, 
surveyed their membership, and they asked the question, ``What 
has been the expenditures getting ready for I-10 plus the 
expenditures remaining to be expended?'' so the results of that 
survey essentially said for a small physician practice where 
that was defined as six or less direct caregivers, the average 
expenditures to date plus anticipated expenditures was roughly 
$8,000.
    Mrs. Ellmers. OK.
    Mr. Averill. And then there were two other studies that 
were recently published that actually came in with lower 
numbers. The market has really responded in terms of making the 
transition much easier and much more cost-effective. As I 
mentioned before, there is lots of free software out there. 
There is lots of free training material and so on. So I think 
in terms of what is available, the transition can be made. I 
think the biggest problem is the uncertainty, the uncertainty 
of should we invest the time, should we move forward when there 
is an uncertain date. You know, it is a tough competition for 
how you are going to spend your dollars. Do you want to spend 
it on ICD-10 preparation when it may not ever occur? The most 
important thing is to say will it occur and when, and for once 
and for all, get that out there and let the industry move 
forward.
    Mrs. Ellmers. So again, just to clarify again from the cost 
standpoint, there is software available that physician offices 
can take part in. There are cost issues that can be addressed. 
And again, that is your position as far as addressing the cost 
issue for physicians and training?
    Mr. Averill. Yes. The market has responded and those 
services are readily available at a very low cost, and it is a 
decision on the part of the individual physician office to take 
advantage of that.
    Mrs. Ellmers. Dr. Terry, would you concur with Mr. Averill 
on that?
    Dr. Terry. I thin, his comments represent the minority. I 
know plenty of physician practices who have paid a lot of money 
to--I mean, if you are stuck with an electronic medical records 
and you don't have a contract that says they are going to 
update it, you are stuck because you can't change it. They 
control our practices now that we got that electronic medical 
records. I have to do what the company tells me to do, and I 
can't bargain. I mean, it costs. I mean, this is--and I respect 
their study but their own people kind of did the study. I mean, 
are there conflict of interest in it? Are there--how is it 
done? Has it been repeated? But I respect what they did but I 
just think it is crazy to say there is zero cost or $5,000 
cost. It is more than that.
    But, you know, cost is not what I am--it is not an issue to 
me. I don't care about that. The thing is the implementation 
and doctors not being able to stay in practice and taking care 
of their patients. I don't really care about the cost.
    Ms. Ellmers. No, and Dr. Terry, I agree. That has been one 
of the issues that I think we all have heard, and those of us 
who have been in the healthcare world, we want to give the best 
care we possibly can to our patients, and when we have been 
whittled down to a few moments in the exam room with them and 
really understanding their issues, it really doesn't matter how 
much information we can gather. We are not gathering it because 
we are basically on a time constraint and there is much that 
will be missed.
    So with that, again, I just want to say thank you, Mr. 
Chairman, and thank you to our panel. This is a very, very 
important issue, and I just hope that we can all come together 
to work on a solution moving forward so that we can continue to 
provide great health care to every American. So thank you.
    Mr. Pitts. The Chair thanks the gentlelady. That concludes 
this round of questioning. We will go to one follow-up per 
side, and I will recognize myself for that purpose.
    Dr. Hughes, when a patient's health care requires multiple 
providers, which coding system will allow the most 
comprehensive detail information sharing to ensure each has the 
best information to care for that patient, ICD-9 or ICD-10, and 
please elaborate.
    Dr. Hughes. ICD-10 provides more information. Let me 
reiterate that for the patient in front of you or in front of 
those several providers, it is not going to make a whole lot of 
difference. Hopefully the several physicians that are caring 
for this one patient are sharing information and they should 
not need a computerized data system in order to learn what 
their colleagues are doing or have done. So for the one 
patient, I don't think it makes a whole lot of difference but 
the difference comes when you are talking about patterns of 
use, when you are talking about how many doctors in this area 
use an assistant surgeon versus another area where you could be 
talking about some pretty considerable differences in cost 
because you get two surgeon bills instead of one, you know, the 
involvement, if there is more than one procedure, then yes, you 
want to have detail, but that is going to be billed anyway.
    I think it is only when we look at the patterns and see how 
the technologies are evolving that that is where it is going to 
be really valuable.
    Mr. Pitts. Does anyone else want to comment on that?
    Dr. Terry. I will just say that I don't treat my patient 
based on a code, and all of these electronic medical records, 
you think my office talks to the doctors in California through 
a computer? No. They don't talk to each other. That code only 
goes to CMS and the insurance companies to do whatever they 
want to do with it. One is to deny payment to us if we don't 
get it right. I don't take care of patients based on a code. 
That is just something else I have to do.
    Mr. Pitts. Anyone else?
    Mr. Averill. I will just make one observation in follow-up 
to that, that much of this additional specificity has been 
requested by the medical community. For example, the urologists 
that have been coming to the coordination maintenance 
committees over the last 3 years have asked for 200 new codes 
to be added to ICD-10, arguing that there is not enough--as 
much specificity as there is in I-10, the urologist community 
is asking for 200 additional diagnosis codes. And so we are 
kind of in a dilemma as an industry. There is continual 
pressure coming from the medical community for more and more 
precise information to be used for everything that we have 
talked about today, and at the same time, there is great 
reluctance to say that we are willing to collect it and submit 
it. So I just find it very interesting that the urologists are 
demanding more and more information and that I-10 becomes 
further and further expanded.
    Mr. Pitts. All right. Thank you. The Chair now recognizes 
the ranking member, Mr. Pallone, for 5 minutes for questions.
    Mr. Pallone. Thank you, Mr. Chairman.
    I just wanted to ask Dr. Burke, you testified that ICD-10 
is a better communications tool. What are some of the critical 
differences between ICD-9 and 10, and how have the more 
specific codes helped you in your practice with patient care?
    Mr. Burke. Well, as I said, it is a better communication 
tool, but I would say, for instance, ICD-9 code would be 
coronary artery disease, but an ICD-10 code could have which 
vessels involved or which graft is involved if the patient has 
had surgery. It was easier to communicate that with the patient 
in describing their clinical condition when you see them.
    Mr. Pallone. I mean, the concern is the large number of 
codes but, I mean, your experience in navigating all these 
codes with more than 100,000, I guess, now, it doesn't matter? 
I mean, in other words, it is not that much more of a burden?
    Dr. Burke. No, not at all.
    Mr. Pallone. OK. Let me just ask, Mr. Chairman, Mr. Averill 
because he was out here, you know, just testifying about the 
cost of another delay. Can you help us understand the effect 
each time implementation is delayed? What does the delay 
affect? What types of, you know, training and resources go into 
preparing for ICD-10 implementation? What is the cost of delay?
    Mr. Averill. Well, I think it is twofold. One, vendors, 
CMS, payers have to essentially maintain dual systems. We have 
to be ready at any point once the final decision is made to go 
fully forward with ICD-10 or continue to support I-9 and all 
the various claims adjudication and all the evaluation of 
quality metrics and so on. We have to have parallel systems. 
That is a tremendous cost.
    Further, the cost of the delay is the uncertainty of it 
all. We have talked a lot about having people be prepared and 
be ready, but in a time of tight expenditures and so on, if you 
are not sure that the date is firm, that is causing many people 
to postpone doing the final preparation to be ready, and so yet 
another delay, frankly, if we go to a third delay, I don't 
believe the industry is going to believe that we will ever move 
forward, and the transition will become that much more 
difficult if and when it ever occurs.
    So after two delays--and I just want to point out, the 
original proposed rule on I-10 was 2011. Then based on public 
comments, it was moved to 2013, and then we have had our two 
delays that have occurred subsequently.
    And so it is the uncertainty of the date that is causing 
the major problems out there in the industry to be absolutely 
at the end of the day prepared for a smooth transition.
    Mr. Pallone. Thank you. Thank you, Mr. Chairman.
    Mr. Pitts. Thank you to each of the witnesses. Excellent 
testimony, very informative, very important.
    We will have follow-up questions from members, those who 
weren't able to attend. We will send those to you in writing. 
We ask that you please respond promptly.
    I remind members that they have 10 business days to submit 
questions for the record. The members should submit their 
questions by the close of business on Thursday, February 26th.
    So with thanks to our panel, without objection, the 
subcommittee is adjourned.
    [Whereupon, at 12:31 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                 Prepared statement of Hon. Fred Upton

    Today the subcommittee will examine the implementation of 
ICD-10--the latest coding system for healthcare providers to 
use for reimbursements and other purposes--set to happen on 
October 1st of this year. Today's hearing is an opportunity to 
learn more about what ICD-10 is, how it can help patients and 
our healthcare system, and whether stakeholders are prepared 
for its implementation later this year.
    The United States is one of the few countries that has yet 
to adopt this most modern coding system. Australia was the 
first country to adopt ICD-10 in 1998. Since then, Canada, 
China, France, Germany, Korea, South Africa, and Thailand--just 
to name a few--have all also implemented ICD-10. In the United 
States, Congress, through one vehicle or another, has prevented 
the adoption of ICD-10 for nearly a decade.
    Under law, ICD-10 is set to become the coding system of the 
United States on October 1, 2015. Understanding that the 
reasons for delay in the past have been credited to 
preparedness, today we look forward to hearing from the 
witnesses on their plans for implementing ICD-10 later this 
year.
    I thank the witnesses for their testimony and 
recommendations.

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