The goal of the CCDS-O program is to develop a mark of excellence for CDI professionals operating in outpatient settings, as well as provide employers with a baseline of competency for existing staff or potential hires. The certification program is also expected to spur the development of core competencies for outpatient CDI professionals and encourage the development and standardization of national best practices for outpatient CDI departments.
The exam's core competencies were developed through a series of interviews with representatives of high-performing outpatient CDI programs in hospitals and healthcare organizations throughout the country. Click here to download the complete outline.
Candidates for the CCDS-O designation must meet educational and work experience requirements. To read a complete breakdown of the requirements, download the Exam Candidate's Handbook.
Candidates for the CCDS-O exam must meet one of the following two education and experience standards:
An RN, MD, DO, or HIM/coding certification (RHIA, RHIT, CCS, CPC, CRC, COC) and two (2) years of experience as an outpatient documentation specialist using United States reimbursement systems.
An RN, MD, DO, or HIM/coding certification (RHIA, RHIT, CCS, CPC, CRC, COC), one (1) year of experience as an inpatient clinical documentation specialist, and one (1) year of experience as an outpatient documentation specialist using United States reimbursement systems.
A year of experience is defined as full-time employment or greater than 2,000 hours worked during that year.
Experience documenting in a medical record as a clinician, resident or equivalent foreign medical graduate does not meet the experience requirement.
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