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