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. Achieving this credential recognizes that a clinical documentation specialist possesses prerequisite educational requirements as well as proven, hands-on experience performing the function of a clinical documentation specialist.
Candidates 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 integrity 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.
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.
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.
*A year of experience is defined as full-time employment or greater than 2,000 hours worked during that year.
Concurrent and retrospective documentation specialists also:
Work collaboratively using real-time conversation with physicians and medical team members caring for the patient
Use their clinical knowledge to evaluate how the medical record will translate into coded data, including reviewing provider and other clinical documentation, lab results, diagnostic information and treatment plans
Communicate with providers, whether in verbal discussion or by query, for missing, unclear or conflicting documentation
Educate providers about optimal documentation, identification of disease processes to ensure proper reflection of severity of illness, complexity, and acuity and facilitate accurate coding
Understand complications, comorbidities, severity of illness, risk of mortality, case mix, and the impact of procedures on the billed record, and share this knowledge with providers and members of the healthcare team
