U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

95–175 PDF 2015

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 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

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 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

SUBCOMMITTEE ON HEALTH

JOSEPH R. PITTS, Pennsylvania 

Chairman 

BRETT GUTHRIE, Kentucky 

Vice Chairman 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

CATHY MCMORRIS RODGERS, Washington 

LEONARD LANCE, New Jersey 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

GENE GREEN, Texas 

Ranking Member 

ELIOT L. ENGEL, New York 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

DORIS O. MATSUI, California 

BEN RAY LUJA ́ N, New Mexico 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(III) 

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. 2The 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. 

Page

IV 

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. Ca ́ rdenas, submitted by Mr. 

Ca ́ rdenas ............................................................................................................... 145 

(1) 

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, Ca ́ rdenas, 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 

2 

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 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. 

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. 

3 

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. 

4 

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 FiVerDate Mar 15 2010 09:40 Jul 21, 2015 Jkt 037690 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114_9ICDX10ASKOK062615\114X9XICD-10XPDFMADE WAYNE
5 

nancial 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 

6 

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 

7 

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:] 

8 

9 

10 

11 

12 

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, 

13 

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:] 

14 

15 

16 

17 

18 

19 

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 

20 

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:] 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

32 

33 

34 

35 

36 

37 

38 

39 

40 

41 

42 

43 

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 guarVerDate Mar 15 2010 09:40 Jul 21, 2015 Jkt 037690 PO 00000 Frm 00047 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114_9ICDX10ASKOK062615\114X9XICD-10XPDFMADE WAYNE
44 

antee 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:] 

45 

46 

47 

48 

49 

50 

51 

52 

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 

53 

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:] 

54 

55 

56 

57 

58 

59 

60 

61 

62 

63 

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 perVerDate Mar 15 2010 09:40 Jul 21, 2015 Jkt 037690 PO 00000 Frm 00067 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114_9ICDX10ASKOK062615\114X9XICD-10XPDFMADE WAYNE
64 

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. 

sonnel 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

65 

66 

67 

68 

69 

70 

71 

72 

73 

74 

75 

76 

77 

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 

78 

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:] 

79 

80 

81 

82 

83 

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 

84 

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? 

85 

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 

86 

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. 

87 

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 

88 

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 

89 

1The 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. 

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

90 

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 

91 

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 uninVerDate Mar 15 2010 09:40 Jul 21, 2015 Jkt 037690 PO 00000 Frm 00095 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114_9ICDX10ASKOK062615\114X9XICD-10XPDFMADE WAYNE
92 

tended 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 feeVerDate Mar 15 2010 09:40 Jul 21, 2015 Jkt 037690 PO 00000 Frm 00096 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114_9ICDX10ASKOK062615\114X9XICD-10XPDFMADE WAYNE
93 

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 secVerDate Mar 15 2010 09:40 Jul 21, 2015 Jkt 037690 PO 00000 Frm 00097 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114_9ICDX10ASKOK062615\114X9XICD-10XPDFMADE WAYNE
94 

tion 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 

95 

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. Ca ́ rdenas, 5 minutes for questions. 

Mr. CA ́ RDENAS. 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. 

96 

Mr. CA ́ RDENAS. OK. So the technology of today makes it much 

less burdensome than the implementation of years past, correct? 

Mr. AVERILL. Correct. 

Mr. CA ́ RDENAS. 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. CA ́ RDENAS. 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. CA ́ RDENAS. 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. CA ́ RDENAS. 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. CA ́ RDENAS. 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. CA ́ RDENAS. 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 

97 

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. CA ́ RDENAS. 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. 

98 

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 

99 

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-yearold 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 

100 

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. 

101 

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. 

102 

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 

103 

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– 

104 

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-yearold 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.’’ 

105 

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. 

106 

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? 

107 

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 

108 

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 

109 

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. 

110 

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. 

111 

112 

113 

114 

115 

116 

117 

118 

119 

120 

121 

122 

123 

124 

125 

126 

127 

128 

129 

130 

131 

132 

133 

134 

135 

136 

137 

138 

139 

140 

141 

142 

143 

144 

145 

146 

147 

148 

149 

150 

151 

152 

153 

154 

155 

156 

157 

158 

159 

160 

161 

162 

163 

164 

165 

166 

Æ