The CCDS-O exam was updated to the CMS-HCC Risk Adjustment Model Version Version 28 on October 1, 2024. Those planning to take the exam should prepare using the second edition of the CCDS-O Exam Study Guide. The first edition of the CCDS-O Exam Study Guide is out of date.
ACDIS developed the Certified Clinical Documentation Specialist-Outpatient (CCDS-O) to provide a trusted baseline of competency for CDI in the outpatient setting, which includes physician practices, hospital clinics, and the emergency department, among other settings.
Click here to download the Exam Candidate Handbook, which includes a complete content outline, candidate prerequisites, and more.
Mission statement
The mission of the CCDS and CCDS-O credentials is to elevate the professional standing of clinical documentation specialists. The program draws from experienced clinical documentation specialists in the field to establish criteria for competency in the broad and multidisciplinary bodies of knowledge clinical documentation specialists must know. These include knowledge of healthcare and coding regulations; anatomy, physiology, pharmacology, and pathophysiology; proficiency in medical record review; communication and physician query techniques; relevant regulatory policy and payment methodologies, and data mining and reporting functions
What is an outpatient documentation specialist?
These functions define the role of an outpatient documentation specialist:
Conducts reviews of medical records for patients in a variety of outpatient settings including but not limited to physician offices, physician and hospital-owned clinics, ambulatory surgery centers, and hospital emergency departments
Collaborates with physicians and medical team members caring for the patient to clarify clinical documentation
Applies their clinical knowledge to evaluate how the medical record will translate into coded data, including reviewing provider and other clinical documentation, chronic disease processes, medications and their indications, diagnostic information, and treatment plans
Communicates with providers, whether in verbal discussion or by query, for missing, unclear or conflicting documentation
Educates providers about optimal documentation and identification of disease processes to ensure proper reflection of severity of illness, complexity, and acuity, and facilitate accurate coding and billing
Understands risk adjusted payment methodologies, professional coding and billing, and outpatient facility coding and billing, and share this knowledge with providers and members of the healthcare team
Candidates taking the CCDS-O exam may to use one of the following drug reference guide during the exam:
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
Books will be checked for additional pages or loose notes inserted or attached inside. These are not allowed to be brought into the testing room. Tabs are permitted in books as are handwritten notes previously written in the margins of books. Candidates may not write in their books during the exam.
