• 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/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.

  • 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/AMP Assessment Centers located around the country (visit www.goamp.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. ACDIS will publish the overall pass rate as soon as it is made available during testing.

  • The Association of Clinical Documentation Integrity Specialists (ACDIS) contracts with Applied Measurement Professionals, Inc., (AMP), a PSI Business, to provide management and examination services. AMP provides administrative support for the certification process, including examination development, validation, and administration. AMP 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.