Individuals who hold the CCDS must apply for recertification every two years. It is due on the anniversary of the date on which they passed the CCDS exam. That date is printed on the individual’s certificate. It is a CCDS holder's responsibility to know their recertification due date. ACDIS sends multiple email reminders to the email address on file. ACDIS is not responsible for late, suspended, or revoked certifications. Please also note that you can find your recertification due date on your account on the certification site.

Employers can also use the Directory of Credential Holders to verify their employee's credential.

Please email the Certification Office at certifications@hcpro.com with any questions.

CCDS

Candidates for the Certified Clinical Documentation Specialist (CCDS) designation must meet educational and work experience requirements. To read a complete breakdown of the requirements, download the Exam Candidate Handbook by clicking here.

The candidate for the CCDS exam will meet one of the following three education and experience standards and currently be employed as either a concurrent or retrospective Clinical Documentation Specialist:

• An RN, RHIA, RHIT, MD, or DO and two (2) years of experience as a concurrent/retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.
• An associate degree (or equivalent) in an allied health field (other than what is listed above) and three (3) years of experience as a concurrent/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 medical terminology, human anatomy and physiology, and disease process, or the AHIMA CCS credential, and a minimum of three (3) years of experience in the role as a concurrent/retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.

*Years of experience is defined as full time employment or greater than 2,000 hours/year

What is an inpatient documentation specialist?

• The concurrent documentation specialist conducts daily reviews of medical records for patients who are currently hospitalized or treated in the inpatient setting
• The retrospective documentation specialist reviews medical records daily of post discharge, pre-bill records

Both 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

Equivalent foreign medical graduate experience documenting in a medical record as a clinician or resident does not meet the experience requirement.

CCDS-O

Candidates for the Certified Outpatient Clinical Documentation Specialist (CCDS-O) designation must meet educational and work experience requirements. To read a complete breakdown of the requirements, download the Exam Candidate 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 outpatient clinical documentation specialist, and one (1) year of experience as an inpatient 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

CCDS

Candidates must complete an online application by clicking here. To login to the application site, ACDIS members can use their regular ACDIS website login credentials. If you do not have a member login, please click the "Register" button.

Please have your education and work history information available prior to starting your application. If you don’t have that available and save a draft of the first page, you will receive an email from us with a link back to the application. In order to complete the application, you will need to click the “Start CCDS Application" (or “Start CCDS-O”) button again. Don’t worry, all the information you did enter will be prefilled, all you will need to do is complete the rest of Page 1 and proceed to Page 2 of the application.

Prometric will send scheduling instructions to the candidate, and the candidate will schedule their own examination. Candidates have three months/90 days from the date their name is submitted to Prometric to schedule and take their exam.

The fee for the certification application process and examination is $280 for ACDIS members and $380 for non-members. Payment may be made by credit card, personal check, or money order payable to HCPro LLC. While fees are non-refundable, payment will be returned if the application is not approved. Please note that your ACDIS membership discount will be automatically applied when you log into the certification site with your membership login.

If you wish to reschedule or cancel, you must contact ACDIS at customerservice@hcpro.com no later than five days prior to your appointment. ACDIS will provide instructions for rescheduling or cancelling your appointment. We recommend you contact ACDIS as soon as possible to give you enough time to receive your instructions and complete your rescheduling or cancellation no later than five days prior to your appointment.

There is no reschedule or cancel fee due to Prometric if you complete your rescheduling or cancellation process 30 or more days before your test date. Prometric charges a fee of $35 if you complete your rescheduling or cancellation process 5-29 days prior to your test date.

You are not permitted to make changes to your exam date or time within five days of your appointment. Four or fewer days prior to the appointment date, the option to reschedule or cancel will not be available and you will forfeit your exam registration and fees if you are not present for the exam.

CCDS-O

Candidates must complete an online application by clicking here. To login to the application site, ACDIS members can use their regular ACDIS website login credentials. If you do not have a member login, please click the "Register" button.

Please have your education and work history information available prior to starting your application. If you don’t have that available and save a draft of the first page, you will receive an email from us with a link back to the application. In order to complete the application, you will need to click “Apply" in the navigation and select CCDS-O again. Don’t worry, all the information you entered will be prefilled, all you will need to do is complete the rest of Page 1 and proceed to Page 2 of the application.

Prometric will send scheduling instructions to the candidate, and the candidate will schedule their own examination. Candidates have three months/90 days from the date their name is submitted to Prometric to schedule and take their exam.

The fee for the certification application process and examination is $280 for ACDIS members and $380 for non-members. Payment may be made by credit card, personal check, or money order payable to HCPro LCC. While fees are non-refundable, payment will be returned if the application is not approved. Please note that your ACDIS membership discount will be automatically applied when you log into the certification site with your membership login.

If you wish to reschedule or cancel, you must contact ACDIS at customerservice@hcpro.com no later than five days prior to your appointment. ACDIS will provide instructions for rescheduling or cancelling your appointment. We recommend you contact ACDIS as soon as possible to give you enough time to receive your instructions and complete your rescheduling or cancellation no later than five days prior to your appointment.

There is no reschedule or cancel fee due to Prometric if you complete your rescheduling or cancellation process 30 or more days before your test date. Prometric charges a fee of $35 if you complete your rescheduling or cancellation process 5-29 days prior to your test date.

You are not permitted to make changes to your exam date or time within five days of your appointment. Four or fewer days prior to the appointment date, the option to reschedule or cancel will not be available and you will forfeit your exam registration and fees if you are not present for the exam.

To become a Certified Clinical Documentation Specialist (CCDS) or a Certified Outpatient Clinical Documentation Specialist (CCDS-O), a candidate must pass the examination. The exam is offered by computer at more than 14,000 Prometric Test Centers located throughout North America and internationally. Click here to see all Test Center locations. Additionally, remotely proctored examinations are offered so that applicants can take the exam from anywhere. To learn more about this option, please visit the ProProctor home page at www.prometric.com/proproctorcandidate.

After you have registered for the examination and received notification of your eligibility, you will receive an email explaining how to schedule your exam with Prometric. Candidates may take their exam at a Prometric testing center or via remote proctoring. If you do not receive your email, or if any information in the email is incorrect or has changed, please contact Customer Service at customerservice@hcpro.com.

CCDS

Candidates taking the CCDS exam may bring the following with them into the test:

• DRG Expert, published by OPTUM, must be an ICD-10 edition. The current edition is published in two volumes and both are permitted for the exam.
• 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

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.

For more information about your exam day, read the Exam Candidate Handbook.

CCDS-O

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.

For more information about your exam day, read the Exam Candidate Handbook.

CCDS

The examination content is based on analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances. Input from a survey taken by members of the Association of Clinical Documentation Integrity Specialists (ACDIS), and the input and research of an advisory board comprised of experienced clinical documentation specialists, was used to identify seven core competencies with which clinical documentation specialists should have a strong working knowledge.

The examination is an objective, multiple-choice test consisting of 140 questions. The examination questions are designed to test the candidate's multidisciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of a clinical documentation specialist. The questions are updated on a continuous basis to keep them relevant to current realities in healthcare. Choices of answers to the examination questions will be identified as A, B, C, or D.

Each question on the examination is categorized by a cognitive level that a candidate would likely use to respond. These categories are:

• Recall questions that test the candidate's knowledge of specific facts and concepts relevant to the day-to-day work of clinical documentation professionals.
• Application questions that require the candidate to interpret or apply information, guidelines, or rules to a particular situation.
• Analysis questions that test the candidate's ability to evaluate and integrate a range of information in problem solving to address a particular challenge.

The current examination is designed so that approximately 40% of the questions will be of the recall type, 40% of the application type, and 20% of the analysis type.

Click here to read the Exam Candidate Handbook, which includes a content outline for the CCDS exam.

Note: The current version of the CCDS exam includes questions based on the following:

• AHA Coding Clinic, through Fourth Quarter 2021
• Fiscal year 2021 ICD-10-CM Official Guidelines for Coding and Reporting
• Guidelines for Achieving a Compliant Query Practice—2019 Update

CCDS-O

The CCDS-O examination is based upon five major content areas. Each of the content areas is briefly described and followed by an outline of the topics included in the area. In addition, the number of examination questions devoted to each major content area is noted.

The examination is an objective, multiple-choice test consisting of 140 questions. The examination questions are designed to test the candidate's multidisciplinary knowledge of clinical, coding, and healthcare regulations, as well as the roles and responsibilities of an outpatient clinical documentation specialist. The questions are updated on a continuous basis to keep them relevant to current realities in healthcare. Choices of answers to the examination questions will be identified as A, B, C, or D.

Each question on the examination is categorized by a cognitive level that a candidate would likely use to respond. These categories are:

• Recall: The ability to recall or recognize specific information
• Application: The ability to comprehend, relate, or apply knowledge to new or changing situations
• Analysis: The ability to analyze and synthesize information, determine solutions, and/or evaluate the usefulness of a solution

Click here to read the Exam Candidate Handbook, which includes a content outline for the CCDS-O exam.

Note: The current version of the CCDS-O exam includes questions based on the following:

• CMS-HCC Risk Adjustment Model Version 23
• AHA Coding Clinic, through First Quarter 2019
• Fiscal year 2019 ICD-10-CM Official Guidelines for Coding and Reporting
• Guidelines for Achieving a Compliant Query Practice—2019 Update
• Queries in outpatient CDI: Developing a compliant, effective process

CCDS

The passing score is 88 correct out of 120 scored questions. Approximately 77% of first-time examinees pass the CCDS.

CCDS-O

The cut score for the CCDS-O exam is 85 out of 120, meaning that the exam candidate must get 85 questions correct out of the possible 120 test questions.

ACDIS has contracted with Prometric to assist in the development, administration, scoring, and analysis of the CCDS and CCDS-O certification examinations. Prometric is a leading provider of technology-enabled testing and assessment solutions to many of the world’s most recognized licensing and certification organizations, academic institutions, and government agencies. Prometric supports more than 7 million test takers annually at its testing locations in more than 180 countries around the world. It also supports remote proctoring, allowing candidates to take their exams from their own homes or elsewhere.

ACDIS maintains all CCDS and CCDS-O program records, handles finances, processes examination and re-examination applications, and manages recertification processes, including requests for continuing education approval.

To learn more about scheduling your CCDS or CCDS-O exam, read the Exam Candidate Handbook.

Benefits for the organization:

• Allows the organization to identify those individuals who have demonstrated knowledge and skills that equip them to function as an effective outpatient clinical documentation specialist
• Demonstrates that individuals are competent to provide ongoing education for physicians and other clinical staff
• Ensures the maintenance of professional standards through the individuals’ commitment to continuing education to maintain certification and stay up to date on regulations and areas that are critical to accurate documentation, coding, and reimbursement
• Provides the organization with peace of mind in knowing that, in an atmosphere of increased government scrutiny, compliance standards are met due to adherence with the ACDIS Code of Ethics

Benefits for the Clinical Documentation Specialist:

• Encourages clinical documentation specialists to hold themselves to a higher standard and obtain the requisite knowledge and skills to fulfill their responsibilities effectively
• Denotes that clinical documentation specialists have achieved a mark of distinction based on an acquired body of knowledge, skills, and experience
• Provides a visible mark of distinction within the organization and the broader CDI profession
• Emphasizes the role of the clinical documentation specialist in the outpatient setting and establishes the clinical documentation specialist profession as key in ensuring healthcare data integrity
• Encourages continued education to keep pace with changing government and private payer regulations and industry standards

Yes! ACDIS members can earn (at least) 10 free CEUs each year. Take the quiz with each edition of CDI Journal quiz (published six times a year) and earn one CEU per edition. Participate in the ACDIS quarterly conference calls and earn one CEU for completing the accompanying survey. ACDIS also routinely offers free and sponsored programs that offer CCDS/CCDS-O CEUs (for example, the annual CDI Week webinar offers one CEU and each episode of the ACDIS Podcast offers 0.5 CEU for the first two days after publication). To read more about earning CEUs, click here.

Also, please note that CCDS CEUs may be used toward your CCDS-O recertification and vice versa. Click here for more information about recertifying both credentials at once.

ACDIS is proud that our credential was recognized by the American Nurses Credentialing Center’s Magnet Recognition Program for many years. The Certified Clinical Documentation Specialist (CCDS) credential was developed through academically rigorous and ethically sound processes that meet all industry standards. Beginning January 2024, the Magnet Recognition Program made the decision to only recognize credentials that have been accredited by the Accreditation Board for Specialty Nursing Certification (ABSNC) or the National Commission Certifying Agencies (NCCA).

It is neither feasible or viable for ACDIS to undergo the application and accreditation process for such designation. We encourage all who are affected by this decision to voice their concerns with the ANCC directly in the hopes that they will reconsider.