Transitioning from ICD-9 to ICD-10: What Knowledge is Needed for a Successful Transition. Breaking News! 3/9/2015

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1 Transitioning from ICD-9 to ICD-10: What Knowledge is Needed for a Successful Transition If you think ICD-10 is all about new codes, you are dead wrong. ICD-10 is really about documentation Chris Polomsky RHIT,CCS,CCDS,CDIP LPN,BA Ahima Approved ICD-10-CM & PCS Trainer Quote is from EHR Intelligence, Why ICD-10 is not just a coding project Breaking News! The Centers for Medicare and Medicaid Services (CMS) have set a new compliance deadline of October 1 st, 2015 for ICD-10- CM and PCS implementation. History What does ICD really mean? It is the International Classification of Diseases which is the global standard for reporting and categorizing diseases, health-related conditions, and external causes of diseases and injuries. It helps to provide a global snapshot of population health. CM is the Clinical Modification for the United States. Originally adopted in 1893 by the International Statistical Institute it was the first International List of Causes of Death. The intent was to revise the list every 10 years and it was revised in 1929, 1938 and In 1946 the original participating governments turned the maintenance of the list over to the World Health Organization which continued to update. ICD-9 was first implemented in 1977 and is obsolete and lacks the flexibility for code expansion. It no longer reflects current clinical knowledge or modern medical practice and terminology. It hinders U.S. efforts to provide clinically relevant and international comparable data. ICD codes are core elements of many HIT or Health Information Technology systems making the conversion to ICD-10 necessary to fully realize the benefits of HIT adoption. The delay in ICD-10 implementation did not come from CMS this year but with some stealthy bipartisanship and legal maneuvering in Washington, D.C. HR 4302 Protecting Access to Medicare Act of 2014 was certainly unprecedented. HR 4302 was originally a bill that provided a temporary patch to the Sustainable Growth Rate. SGR is a formula used by Medicare to reimburse physicians. It was going to see a 24% reduction in physician Medicare payments on March 31 st, Congress appeased physicians by introducing language into the bill on March 26 th of this year that delayed implementation by one year. As an educator this was very disheartening. This delay impacts over 26,000 HIM students nationwide and their job prospects as they had only been taught the ICD-10 code set and not ICD-9 in preparation for the October 1 st 2014 implementation date. 1

2 With all this being said we should still stay the course and providers should continue clinical documentation improvement and coder and physician education and training. Especially in the arena of clinical documentation as this can only help in both ICD-9 & 10. Did You Know? All other industrialized nations have implemented ICD-10 in advance of the United States. More than 100 countries use the system to report mortality data, a primary indicator of health status ICD has been translated into 43 languages That the development of ICD-10-CM began in the US in 1994 under the leadership of NCHS and in 1997 the first draft was made available for public comment Did You Know? The United States is the only country to use the ICD system as part of its healthcare reimbursement which accounts for some of the delay in implementing the 10 th revision. The 43 rd World Health Assembly endorsed the ICD-10 in May of 1990 and member states began implementation of new codes in 1994 ICD-10 Implementation Dates United Kingdom 1995 France 1997 Australia 1998 Germany 2000 Canada 2001 USA 2015??? The WHO is currently working on the 11 th revision with an anticipated release of Quick Reimbursement Primer Medicare has been reimbursing healthcare based on actual charges since October 1983 the federal government created the IPPS which stands for Inpatient Prospective Payment System which changed the payment method to one of fixed rates determined by a diagnosis-related group or DRG which is based on the assignment of ICD-9 codes and their sequencing. This certainly underscores the value of our coding system here in the U.S. Reimbursement Primer Continued: Under IPPS, CMS categorized each patient s case into a DRG under the theory that like patients would have like treatments and charges based on the patient s principal diagnosis, secondary diagnoses and any associated procedures which, depending on the procedure change a medical DRG to a surgical DRG typically a higher-paying DRG. Certain diseases or conditions thought to increase the complexity of the case were classified as complications or cormorbidities. CC s as they are commonly referred to. 2

3 Reimbursement Primer Continued: CC s are identified by their ICD-9-CM code and normally increases the patient s LOS by one day in 75% of the cases reviewed. For example acute blood-loss anemia or D62 in ICD-10-CM Major cormorbidities or MCC s are diagnoses such as: ESRD or N18.6 in ICD-10-CM Encephalopathy, Unspecified which is G93.40 in 10. Any MI: NSTEMI or I21.4 in ICD-10-CM Reimbursement Primer Continued: Some providers and states, Maryland, for example use an APR-DRG classification system or All-Patient- Refined system created by 3M that differentiates the patients along 2 different scales: that of SOI or severity of illness or ROM or risk of mortality. This expands CMS s original DRGs into one of four possible groups within each scale: Minor =1 Moderate =2 Reimbursement Primer Continued: Major =3 Extreme =4 The APR-DRG system classifies patients with secondary diagnoses that may or may not be a CC in the DRG system. This allows hospitals to quantify and qualify clinical acuity of different patient populations. Two hospitals can have the same volume of a patient type that falls into a particular DRG but they can have vastly different SOI, ROM and APR-DRG values. Reimbursement Primer Continued: The original DRG s of the 1980 s did not provide enough variation among patients and reimbursement levels. In 2007, CMS developed a new formula to more accurately capture resources and severity with the Medicare Severity Model or MS-DRGs. This new system has increased the number of DRG s to nearly 750. Each DRG can either stand alone or be in a pair or duo or in a triplet, trio or triad. CHF DRG Example: A Triplet DRG Let s take a DRG that you are all very familiar with as it is a target for readmissions within 30 days. DRG 293: Heart Failure and Shock without CC/MCC (RW.9916, average LOS 3.2 days) DRG 292: Heart Failure and Shock with CC, add a hyponatremia or E87.1 or a Body Mass Index of over 40 V85.41 or Z68.41-Z68.42 (RW , average LOS 4.7 days) CHF DRG Continued: DRG 291: Heart Failure and Shock with MCC, add ESRD or N18.6 or Pneumonia, unspecified 486 or J18.9 ( RW , average LOS 6.1 days) Documentation, documentation, documentation in any code system, ICD- 9 or ICD-10 is the key factor. 3

4 These DRG s are classified into levels of severity for their diagnostic categories or Major Diagnostic Categories as shown by the CHF DRG example which falls into MDC 5, Diseases and Disorders of the Circulatory System. They range from highest severity indicator to lesser and then lowest level of severity and resource consumption. CMS annually reviews the RW, relative weight, or payment factor to ensure the accurate reflection of resource consumption. In the 2011 IPPS update it was noted that there was a $27,000 difference in the cost of an allogenic versus an autologous bone marrow transplant. These were then separated into DRG s 14 and 17, respectively to provide more accurate reimbursement for each procedure. DRG 14 for the Allogenic Bone Marrow Transplant carries a RW of with an average LOS of 24.8 while a Autologous Bone Marrow Transplant has a RW of 4.29 and an average LOS of 14.6 days. Today the difference in base reimbursement between the two DRG s is approximately 35 thousand dollars. Progression Of IPPS DRG implemented in the United States increasing importance of ICD-9 coding 1990: 3M develops the APR-DRG system : ICD-10-CM/PCS implementation starts outside the United States 2007 MS-DRG system implemented highlighting the need for and importance of greater specificity in coding and documentation. In 2013 the National Center for Health Statistics (NCHS) revised the draft ICD-10-CM Official Guidelines for Coding and Reporting. These guidelines have been approved by the 4 organizations referred to as the Cooperating Parties for ICD-10- CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS) and NCHS. These guidelines are the backbone of the coding world and our justification for physician questions of why do we have to do it like this? One of the most common difference between the coding world and the clinical world is the use of ACS or acute coronary syndrome or in the coding world 411.1(I20.0) which is unstable angina. To most clinicians it means an M.I. Another example of this is the word urosepsis which to many physicians means sepsis but that is far different than a UTI (N 39.0) to which urosepsis corresponds to in the ICD-9-CM coding world. In fact in ICD-10-CM there is no listing for urosepsis at all. It will result in documentation requests and coding queries. So what really is the big difference? Is it only the number of codes? That fact alone is daunting as diagnoses alone will increase from 14,567 to 69,823. Think of this: 47 codes possible for a fracture of a radius/ulna in ICD-9-CM but >1,800 codes in ICD-10-CM for fracture of radius However the procedure codes alone will increase from 3,882 now contained in Volume 3 of ICD-9 to 71,924 in PCS. Benefits and Goals of ICD-CM/PCS Additional codes provide additional specificity, frequently called granularity to describe the condition of the patient This data can more accurately illustrate disease trends which can lead to changes in how healthcare is provided Helpful for clinical research Improved ability to measure healthcare services, including quality and patient safety data 4

5 Benefits and Goals continued: Expanded ability to conduct public health surveillance More sensitivity for refining grouping and reimbursement methodologies Decreased need to include supporting documentation with claims because it will be included in codes Sharing and comparing health information between hospitals, regions and countries More clinically relevant than ICD-9 Benefits and Goals Continued: Enhanced detail on socioeconomic conditions, ambulatory care conditions, family relationships, results of screening tests and problems related to lifestyle Increased use of data to evaluate medical processes and outcomes and conduct biosurvelliance Administrative data to support value-based purchasing initiatives Benefits and Goals Continued: Increased level of detail will more accurately depict a patient s severity and provide more information between a provider s performance and the patient s condition and complexity Good clinical documentation promotes better patient care and more accurate capture of acuity, severity and risk of mortality Less ambiguous code choices Support for medical necessity Benefits and Goals Continued: Validation for physician reporting of evaluation and management codes Less misinterpretation by auditors, attorneys and other 3 rd parties (commercial payers, BWC) Fewer rejected and improper reimbursement claims Increased use of automated tools to facilitate the coding process (CAC or Computer-Assisted-Coding) Fewer coding errors Increased Productivity ICD-10-CM Specificity Differences between ICD-9-CM & 10 Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Letter Number Number or letter (first 3 characters are the Category) Number or letter (for 4, 5,6 & 7 or Subcategory) Also identifies etiology, anatomic site and severity Character 7 (the extension code for OB, injuries, external causes) Volumes 1 & 2 of ICD-9 Impairments & their To date: 14,567 codes The entire book of ICD-10 CM will encompass everything listed in one volume or book To date : 69,823 codes 5

6 Organizational and Structural Changes: Organizational and Structural Changes Continued: ICD-9- CM ICD-10-CM ICD-9-CM ICD-10-CM 17 chapters (currently eye and ear are included in Nervous System chapter) No laterality codes No placeholder characters for code expansion 3-5 character codes 21 chapters (eye and ear new chapters) Laterality codes Placeholder character for expansion. Always letter X 3-7 character codes First digit is numeric but can be alpha (E or V) Second, third, fourth and fifth digits are numeric First character is always alpha All letters used except U Character 2 is always numeric Characters 3 through 7 can be alpha or numeric Did You Know? Organization and Structural Changes Continued: Why isn t the letter U used? It has been reserved by the WHO for the provisional assignment of new diseases of uncertain etiology (U00-U49) and for bacterial agents resistant to antibiotics (U80- U89) ICD-9-CM Always at least 3 digits (Hypertension, unspecified is 401.9) Decimal placed after the first 3 characters Alpha characters are not case-sensitive ICD-10-CM Always at least 3 digits (Hypertension, unspecified I10) Decimal placed after the first 3 characters Alpha characters are not case-sensitive Similarities to ICD-9-CM Both with chronological list of codes divided into chapters based on body system or condition Same hierarchical structure Index still contains an alphabetical list of terms and their corresponding codes Indented sub terms under main term Same structure with the Alpha Index of Diseases and Injuries Similarities to ICD-9-CM Alphabetic Index of External causes Table of Neoplasms Table of Drugs and Chemicals Coding conventions have the same meaning, abbreviations, punctuations, notes such as code first and use additional code Non specific codes still available ( unspecified or not otherwise specified ) Codes are invalid if missing an applicable character 6

7 A Few Important Changes to ICD-10-CM The addition of the 7 th character especially in the chapters of pregnancy, injury and external causes Expansion of postoperative complications with distinctions between intraoperative and post procedural Instructional notes, guideline and time frame changes Seventh characters added for type of encounter for injuries and external causes as well as multiple gestations in the Obstetric chapter A Few Important Changes to ICD-10-CM Continued: Expanded use of combination codes for certain conditions and associated common manifestations of symptoms and poisoning and associated external cause codes Some examples: I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris In ICD-9-CM requires 2 codes: & M80.08xA Age-related osteoporosis with current pathological fracture, vertebrae, initial encounter Placeholder X The addition of this code will allow for future expansion Fills out empty characters when a code contains fewer than 6 characters and a 7 th character applies When a placeholder character applies it must be used in order for the code to be valid X is not case-sensitive Example: T46.1x5A or T46.1X5A for Adverse effect of calciumchannel blockers, initial encounter (either is correct) Seventh Characters Seventh characters may be either alpha or numeric and are added to the end of the code in the seventh position to provide additional information about the characteristics of the encounter. There are different meanings depending on the section it is being used. As shown in the example in the previous slide the A is a seventh character signifying that it is the patient s first encounter for this condition. There are currently 16 applicable 7 th characters depending on the injury or condition. Some of the most common that we will probably see and use are: A initial encounter D subsequent encounter S sequela For Fracture Coding: D encounter for fx with routine healing G subsequent encounter for fx with delayed healing K subsequent encounter for fx with nonunion P subsequent encounter for fx with malunion Examples of Use of 7 th Characters: O32.1xx2 Maternal care for breech presentation, Fetus 2 M1A.0620 Idiopathic chronic gout, left knee, without tophus V73.6xxA Passenger on bus injured in collision with car, pickup truck or van in traffic accident, initial encounter 7

8 A Few Important Changes to ICD-10- CM Continued: Excludes1 and 2 notes. Excludes 1 note indicates that the code identified in the note and the code where the note appears cannot be reported together because the 2 conditions cannot occur together. Example: E10 Type 1 Diabetes Mellitus cannot be reported with E11.1- Type 2 Diabetes Mellitus Excludes Notes: Excludes2 note indicates that the condition identified in the note is not part of the condition coded so both can be reported if the patient has both conditions. Example: L89 Pressure Ulcer may be reported with diabetic ulcers, skin infections (L00-l08) or even varicose ulcers (I83.0, I83.2) A Few Important Changes to ICD-10- CM Continued: Postoperative complications have been moved to the procedure-specific body system chapter Example: Postoperative hematoma following cardiac catheterization I This code will be found in Chapter 9 of the ICD-10-CM book, Diseases of the Circulatory System. Time frame changes : Age of an acute myocardial infarction changing from 8 weeks in ICD-10-CM to only 4 weeks in ICD-10-CM that will pose challenges for coders based on current documentation. A Few Important Changes Continued: The words ante partum, postpartum no longer used in assigning obstetric codes. It will be based on gestational weeks or trimesters and assigned a Z3A.- based on length of gestation. Thankfully most obstetricians always document weeks and days. Example: Moderate pre-eclampsia, 23 weeks O14.02 Mild to moderate pre-eclampsia, second trimester Clinical Concepts in ICD-10 Diagnosis Codes Initial encounter Subsequent encounter Sequela 1 st, 2 nd or 3 rd trimester Weeks of gestation Right (laterality) Left (laterality Routine healing More Clinical Concepts: Delayed healing Assault Nonunion (fracture) Malunion (fracture) Self-harm Accidental Underdosing (new concept in ICD-10-CM to capture data for financial hardship reasons, age-related debility or other reasons) 8

9 Clinical Concept Example: Diabetes Mellitus In the following list, concepts that are included in ICD-10, but not in 9 are italized. Think of your documentation in your facilities and see if it lacking? Type of diabetes: type I, type 2, underlying condition, drug or chemical induced, pre-existing, gestational and neonatal Diabetes in pregnancy: first trimester, second trimester, third trimester, childbirth, puerperium ICD-10- Clinical Concepts for DM continued: Neurological complications: neuropathy, mononeuropathy, polyneuropathy, coma, autonomic neuropathy, amyotrophy, neurological complication Lab Findings: ketoacidosis, hyperosmolarity, hyperglycemia and hypoglycemia Skin complications: dermatitis, foot ulcer, skin complications, skin ulcer Joint complications: neuropathic arthropathy, arthropathy Clinical Concepts for DM continued: Oral complications: oral complications, periodontal disease The number of diagnosis codes for diabetes increases from 69 in ICD-9 to 239 in ICD-10. With this in mind providers have time to ensure we have all the documentation needed for ICD-10 coding. The addition of these clinical concepts will better translate the details about a patient s clinical condition. Case Managers and Clinical Documentation Challenges The delay gives us a chance to dig deeper into inpatient, ambulatory, outpatient and physician practices to identify areas of greatest risk. Identify documentation improvement opportunities that could impact multiple initiatives: medical necessity and patient safety indicators Careful consideration should be given to: High risk and high volume procedures High volume DRG s Cases with long lengths of stay CM s and Clinical Documentation Challenges cont.: Key to quality care is focusing on capturing quality information at the point of care We need good clinical documentation not more volume Improving clinical documentation right now has immediate benefits In all cases documentation indicates the services that may be reported CM s and Clinical Documentation Challenges cont: The importance of complete and consistent documentation in the medical record cannot be overemphasized. Case Managers are at the front line! 9

10 Differences in ICD-9-CM & PCS What to Remember-There Really is No Comparison!!! ICD-10-PCS Procedure Classification System If a procedure an be performed, a code was created! Quote from HCPro/Revenue Cycle Institute Volume 3 of ICD-9-CM This code set reports procedures or other actions taken for diseases, injuries or impairments To date: 3,882 codes PCS or Procedure Classification System will replace Volume 3 and be a complete and separate book To date : 71,924 codes Inpatient use only. CPT codes for physician billing and outpatient procedures remain the same. ICD-10-PCS Number of PCS Codes by Section: Some Examples: All codes are 7 characters, NO EXCEPTIONS All possible procedures are defined 34 possible values for each character Numbers used are 0 through 9 Letters used are A-H, J-N, P-Z No letter I or O used unlike CM (too confusing with numbers 1 and 0) PCS is broken up into 16 sections and these are subdivided into 3 main sections: Med/Surg section, Med/Surg-related sections and Ancillary sections are the There are some sections with as few as 30 codes and others with thousands Medical and Surgical Obstetrics Placement Administration Measurement & Monitoring Imaging Radiation Oncology Rehabilitation and Diagnostic Audiology Over 61, , ,934 1,939 1,380 ICD-10-PCS Code Structure: Medical and Surgical Section (Roughly 86% of codes) Character 1: Section Character 1 Character 2 Character 3 Character 4 Character 5 Character 6 Character 7 Section Body System Root Operation Body Part Approach Device Qualifier Med/Surg Section -0 Med/Surg-related Sections: 1-Obstetrics 2-Placement 3-Administration 4-Measurement & Monitoring 5-Extracorporeal Assistance & Performance 6-Extracorporeal Therapies 7-Osteopathic 8-Other procedures 9-Chiropractic 10

11 Character 1: Sections cont. Ancillary Sections: B-Imaging C-Nuclear Medicine D-Radiation Oncology F-Physical Rehab and Diagnostic Audiology G-Mental Health H-Substance Abuse Treatment Examples of a PCS Code in the Medical and Surgical System: 04V03DZ : Sounds like Greek? It s counterpart in the ICD-9 world is Let s break it down: 0 for the Medical and Surgical section 4 for the Body System, in this case Lower Arteries V for the Root Operation, Restriction 0 for the Body Part, Abdominal Aorta 3 for the Approach, Percutaneous D for the Device, Intraluminal Device Z for the Qualifier, in this case none, which defaults to Z The PCS code we just reviewed is the correct code assignment for a repair of abdominal aortic aneurysm using an endovascular stent graft to restrict the lumen of the aneurysmal aorta via transfemoral catheter approach. Code Comparison Between 9 and 10 Method of repair will impact code assignment clipping, coagulation, coil, resection of vessel, graft replacement etc. Location of aneurysm does impact code assignment Approach will impact code assignment - open, percutaneous, perc. endoscopic Location of aneurysm will impact code assignment Use of a device or none at all will affect code assignment Documentation Needed from Physicians ICD-9 vs PCS Character 2: Body System Method of repair Body part where aneurysm is located Approach Body part where aneurysm is located Type of device used, if any Defines the general physiological system on which the procedure is performed Anatomical region where the procedure is performed 0-Central Nervous System 1-Peripheral Nervous System 2-Heart and Great Vessels 3-Upper Arteries 4-Lower Arteries (shown in our earlier example) 11

12 Character 2: Body System cont. Character 3: Root Operation Continues through number 9, then B-H, J-N, P-Y B-Respiratory System C-Mouth and Throat U-Female Reproductive System V-Male Reproductive System W-Anatomical regions, general (ex. oral cavity, pleural & peritoneal cavity) X-Anatomical regions, upper extremities Y-Anatomical regions, lower extremities The root operation defines the objective of the procedure If multiple procedures are performed, as defined by distinct objectives, then multiple codes are assigned There are 31 root operations in the medical and surgical section These 31 can be arranged into 9 groups with similar characteristics Character 3: Root Operations cont. Root operations that take out some or all of a body part (5) Ex. B-Excision or 6-Detachment Root operations that take out solids, fluids or gases from a body part (3) Ex. C- Extirpation Root operations that involve cutting or separation only (2) Ex. 8-Division or N-Release Root operations that put in, put back or move some or all of a body part (4) Ex. S-Reposition or X- Transfer Character 3: Root Operations cont. Root operations that alter the diameter or route of a tubular body part (4) Ex. 1-Bypass or L-Occlusion Root operations that always involve a device (6) Ex. 2-Change, H-Insertion or R-Replacement Root operations that involve examination only (2) Ex. J-Inspection or K-Map Root operations that include other repairs (2) Ex. 3- Control or Q-Repair Root operations that include other objectives (3) Ex. 0-Alteration, 4-Creation or G-Fusion0 Character 3: Root Operations continued: Common Terminology Character 4: Body part ICD-9 Thrombectomy Amputation Lithotripsy PTCA Lysis of Adhesions Flap Graft Reduction of Displaced Fracture PCS Extirpation (C) Detachment (6) Fragmentation (F) Dilation (7) Release (N) Transfer (X) Reposition (S) Body part defines the specific anatomical site where the procedure is performed Up to 34 possible body part values in each body system Appendix C in the back of the PCS book helps translate anatomical terms into a PCS description Ex. Medial rectus muscle can be extra ocular muscle right or left Using our example from earlier in the abdominal aneurysm repair there are 31 possible body part values to choose from 0-Abdominal Aorta, some others are 9-Renal Artery, Right or W- Foot Artery, Left 12

13 Character 5: Approach Approach defines the technique used to reach the site of the procedure There are 7 different approach values Approaches through the skin or mucous membranes 0- Open 3- Percutaneous (approach used in our example) 4- Percutaneous Endoscopic Character 5: Approaches cont. Approaches through an orifice 7- Via natural or artificial opening 8- Via natural or artificial opening endoscopic F- Via natural or artificial opening with percutaneous endoscopic assistance External X- Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane Character 6: Device Includes only devices that remain after the procedure is completed (our procedure example had a device that remained) Devices not included are materials that are incidental to a procedure such as clips, drains, sutures. Devices that are included are: Biological or synthetic material that takes the place of all or a portion of a body part (joint prosthesis) Character 6: Devices cont. Devices that are included are: Biological or synthetic material that assists or prevents a physiological function (IUD, urinary catheter) Mechanical or electronic devices used to assist, monitor, take the place of or prevent a physiological function (pacemaker) Appendix D in the PCS book is the Device Key and Aggregation Table (Ex. For a Colonic Z-Stent use Intraluminal device ) Character 7: Qualifier Comparison of CABG Procedure Defines an additional attribute of the procedure performed, if applicable May have a narrow application to a specific root operation, body system or body part For example, the qualifier can be used to identify the destination site in a Bypass or indicate single, multiple or all in Excision of teeth. ICD-9 9 total codes to describe different versions of CABG 4 codes specify number of coronary arteries bypassed 4 codes specify source of new blood flow 1 code for unspecified, no such thing in PCS, all codes have a minimum level of specificity Aortocoronary Bypass, one coronary artery PCS 34 unique codes Number of coronary artery sites bypassed Approach to procedure site Type of graft used if any Origin of the bypass (source of new blood flow) W Bypass of coronary artery, one site to aorta with autologous venous tissue, open approach 13

14 Questions? Comments Reference/Resource List The Clinical Documentation Improvement Specialist s Guide to ICD-10, Second Edition ICD University MLN Connects (CMS website) ICD 10monitor enews sponsored by ICD Logic 14