Certified Clinical Documentation Specialist (CCDS)
Anybody who is interested in clinical documentation and wishes to work as a Physician advisor or a part time Clinical documentation improvement (CDI), [also known as “clinical documentation integrity”], having a CCDS certification will help you. Many hospitals now ask for some sort of certificate to prove you have knowledge and understanding in the field.
CCDS certificate is considered gold standard for folks who wish to pursue CDI. The Certified Clinical Documentation Specialist (CCDS) examination is designed to test an applicant’s ability to recall documentation and coding guidelines and industry regulations pertaining to clinical documentation improvement and apply that knowledge to real-life scenarios clinical documentation specialists face every day.
CCDS exam overview:
As per ACDIS, CCDS certification has the following objectives.
Provides special recognition to those clinical documentation specialists who demonstrate mastery of an acquired body of knowledge and skills in clinical documentation integrity through successful completion of the certification process.
Promote documentation and medical records integrity by helping clinical documentation specialists define and obtain the requisite knowledge and skills necessary to fulfill their responsibilities.
Support compliance efforts by promoting a Code of Ethics for clinical documentation integrity specialists.
Assist hospitals and healthcare entities in identifying individuals with substantive knowledge, experience, and skills in clinical documentation integrity for the benefit of their organization.
CCDS Requirements & Pre-requisites:
Candidates who apply for the examination must:
List their documentation specialist experience. Applications may be audited to verify work history and educational background.
Have at least two years of experience as a documentation specialist. Once a candidate has accumulated the time, it does not expire.
Meet the work experience requirements prior to submitting their application.
The candidate for the CCDS exam must meet one of the following three education and experience standards and currently be employed as either a concurrent or retrospective Clinical Documentation Improvement Specialist:
- An RN, RHIA, RHIT, MD or DO and two (2) years of experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.
2. An Associate’s degree (or equivalent) in an allied health field (other than what is listed above) and three (3) years of experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system. The education component must include completed college-level course work in medical terminology and human anatomy and physiology.
3. Formal education (accredited college-level course work) in human anatomy and physiology, medical terminology, and disease process, or the AHIMA CCS or CCS-P credential, and a minimum of three (3) years of experience in the role as a concurrent or retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.
How to apply for the CCDS exam?
Complete an online application by clicking here
The fee for the certification application process and examination is $255 for ACDIS members and $355 for non-members.
Examinations are offered by computer at approximately 300 PSI/AMP Assessment Centers located throughout the United States.
Apply to re-take the examination after failing:
If a candidate fails the exam, they may take it again after waiting 90 days from the date of the failed exam. ACDIS will discount the exam fee to $125 for the first retake only. Subsequent attempts to pass the exam will be at full price.
Resources and Exam Preparation:
The current version of the CCDS exam includes questions based on the following:
What helped me pass the CCDS Exam?:
I have read all the above pdf documents and read the recent version of the CCDS exam study guide book. But the actual thing that helped me the most was my actual CDI specialist experience from 6 years where we actually go through charts daily, query the physicians, identify the Complication or Comorbidity and Major Complication or Comorbidity [CC/MCC], compute Diagnosis-Related Group [DRG] based on guidelines, identify ways to increase the Severity of Illness/Risk of. Mortality [SOI/ROM], identify the PSI (Patient Safety Indicators), Hospital Acquired Conditions (HACs) and complications and how to avoid them with clear and concise documentation, interaction with the coders and learning some points from them etc. Also there is a 100 question practice exam in the CCDS exam study book which helped me understand how the questions would be. I took the practice exam 4 times as there were some good learning points too.
I strongly recommend to follow each and every point in the CCDS candidate handbook which is the third link attached above.
You can find all the resources and links through this site.
CCDS exam allowable resources:
Examination takers for the CCDS are allowed to bring the following two resources with them into the examination:
1. DRG Expert, published by OPTUM (the 2019 edition is published in two volumes)
2. One of the following standard drug reference guides:
– Nursing Drug Handbook/Lippincott’s
– Mosby’s Nursing Drug Reference
– Physicians’ Desk Reference (or PDR Nurse’s Drug Handbook)
– Pearson’s Nurse’s Drug Guide
– Saunders Nursing Drug Handbook
– Davis’s Drug Guide
The CCDS exam covers the following core competencies:
Healthcare regulations, reimbursement, and documentation requirements related to the IPPS, Inpatient Prospective Payment System.
Anatomy and physiology, patho-physiology, pharmacology, and medical terminology.
Medical record documentation.
Healthcare facility CDI program analysis.
Official Guidelines for Coding and Reporting.
Professionalism, ethics, and compliance
Impact of Reportable Diagnoses on Quality of Care
Day of the CCDS Exam:
I took the online exam that is offered at various PSI locations.
Arrive half hour before with ID proofs like Drivers license, Passport or Card with signature.
There were 120 questions and you have 3 hours to complete.
I just had 5 minutes left by the time I finished with all questions. Some of the questions were little tricky, so you can always bookmark them and come back later to answer if you are not sure of the answer. I suggest you not to waste time on the ones you do not know.
I would say the exam will be kind of tough to those who do not have any CDI experience when you try to pass the exam just by reading books and articles.
CCDS certificate is more useful for those who want to pursue a career in CDI field.
[This is a guest post from a doctor who wants to be anonymous]