• Our testing partner, PSI, owns and operates a network of more than 1800 global testing centers. These test sites closed shortly after the outbreak of COVID-19, but beginning Friday, May 1 they began to reopen.

    You can find a list of closed test sites here: https://www.psionline.com/closures. This list is updated regularly and serves as the best reference.

    Openings are subject to guidelines from local and state governments, and testing center availability will be affected in the short term.

    How will testing work? 
    If you are a CCDS/CCDS-O candidate planning to schedule an exam, only OPEN test center locations will show on the PSI site. Candidates won’t have to determine whether a particular testing center is open or closed. For example, if a site is slated to open on May 20, and a candidate attempts to schedule on May 1, that particular site will show as available starting May 20. 

    All candidates currently scheduled to take a certification exam have been granted a grace period until June 30, 2020, to reschedule their exam without penalty or additional fee.

    If you have further questions, please contact our Customer Care at customerservice@hcpro.com or 800-650-6787.

  • ACDIS is proud to be recognized by the American Nurses Credentialing Center’s Magnet Recognition Program.

    https://www.nursingworld.org/organizational-programs/magnet/accepted-certifications/

    Click the link for the National Certifications Currently Included in the DDCT (xls) file and search for “Certified Clinical Documentation Specialist.”

  • 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 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.

    Certification holders can look up their due date on the CCDS Certification Holders page using the posted PDF list. Employers can also use this list to verify their employee's credential.

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

  • 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's Handbook by clicking here.

    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
  • 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-O Application" 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.

    PSI 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 PSI to schedule and take their exam.

  • To become a Certified Outpatient Clinical Documentation Specialist (CCDS-O), a candidate must pass the examination. The exam is offered by computer at more than 300 PSI Assessment Centers located around the country (visit https://www.psionline.com/ and follow the links to find locations and directions).

    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-O Application" 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.

    PSI/AMP 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 PSI/AMP to schedule and take their exam.

  • 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.

  • 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.

    The examination is composed of 140 multiple-choice questions. 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
  • 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 composed of 140 multiple-choice questions.

    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’s 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:

  • The CCDS-O exam launched in test centers nationwide in April 2019 and the cut score has been set to 85 out of 120, meaning that the exam candidate must get 85 questions correct out of the possible 120 test questions.

  • The Association of Clinical Documentation Integrity Specialists (ACDIS) contracts with PSI to provide management and examination services. PSI provides administrative support for the certification process, including examination development, validation, and administration. PSI carefully adheres to industry standards for development of practice-related, criterion-referenced examinations to assess competency.

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

  • 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 compelting the accompanying survey. ACDIS also routinely offers free and sponsored programs that offer CCDS-O CEUs (for example, the annual CDI Week webinar offers one CEU). To read more about earning CEUs, click here.

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

  • 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 compelting the accompanying survey. ACDIS also routinely offers free and sponsored programs that offer CCDS CEUs (for example, the annual CDI Week webinar offers one CEU). To read more about earning CCDS CEUs, click here. Click here for more information about recertifying both the CCDS and CCDS-O credentials at once.

  • 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 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 hospital quality initiatives
    • 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
    • Establishes leadership within their profession and provide physicians and clinical staff with education regarding documentation requirements
    • Emphasizes the role of the clinical documentation specialist within the health information management (HIM) arena 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
  • The Association of Clinical Documentation Improvement Specialists (ACDIS) contracts with PSI to provide management and examination services. PSI provides administrative support for the certification process, including examination development, validation, and administration. PSI carefully adheres to industry standards for development of practice-related, criterion-referenced examinations to assess competency.

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

    To learn more about scheduling your CCDS or CCDS-O exam, watch this video with former Certification Coordinator Penny Richards.

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

    To learn more about CCDS and CCDS-O exam results, watch this video with former Certification Coordinator Penny Richards.

  • 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.

    Click here to read the Exam Candidate's Handbook which includes content outlines for the CCDS and CCDS-O exams.

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

    To learn more about the exam day, watch this video with former CCDS Coordinator Penny Richards.

  • 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.

    • Recall questions test the candidate's knowledge of specific facts and concepts relevant to the day-to-day work of clinical documentation professionals.
    • Application questions require the candidate to interpret or apply information, guidelines, or rules to a particular situation.
    • Analysis questions 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.

    To learn more about the exam day, watch this video with former CCDS Coordinator Penny Richards.

  • Candidates may bring the following with them into the test:

    • DRG Expert, published by OPTUM, must be and 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 examination room. Page tabs are permitted.

    To learn more about the exam day, watch this video with former CCDS Coordinator Penny Richards. For more tips about your exam day, read the Exam Candidates Handbook.

  • 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" 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.

    PSI/AMP 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 PSI/AMP to schedule and take their exam.

    The fee for the certification application process and examination is $255 for ACDIS members and $355 for non-members. Payment may be made by credit card, personal check, or money order payable to HCPro, Inc. 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.

  • 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 300 PSI Assessment Centers located around the country (visit www.schedule.psiexams.com and follow the links to find locations and directions).

    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" 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.

    PSI 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 PSI to schedule and take their exam.

  • 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's Handbook by clicking here. To download a quick reference flowchart, click 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’s 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 a concurrent documentation specialist?

    The concurrent documentation specialist:

    • Reviews medical records daily and in the current time, while the patient is hospitalized
    • Works collaboratively using real-time conversation with physicians and medical team members caring for the patient
    • Uses his or her 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
    • Communicates with providers, whether in verbal discussion or by query, for missing, unclear, or conflicting documentation
    • Educates providers about optimal documentation, identification of disease processes that reflect severity of illness, complexity, and acuity to facilitate accurate coding
    • Understands complications, comorbidities, severity of illness, risk of mortality, case mix, and the impact of procedures on the billed record, and shares this knowledge with providers and members of the healthcare team

    What is a retrospective documentation specialist?

    The retrospective documentation specialist:

    • Daily reviews medical records of post discharge, pre-bill records
    • Works collaboratively using real-time conversation with physicians and medical team members who cared for the patient
    • Uses his or her 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
    • Communicates with providers, whether in verbal discussion or by query, for missing, unclear, or conflicting documentation
    • Educates providers about optimal documentation, identification of disease processes that reflect severity of illness, complexity, and acuity to facilitate accurate coding
    • Understands complications, comorbidities, severity of illness, risk of mortality, case mix, and the impact of procedures on the billed record, and shares this knowledge with providers and members of the healthcare team

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