To become a Certified Clinical Documentation Specialist (CCDS), a candidate must pass the examination. This examination is offered in two methods:
- Via paper-and-pencil at the Association of Clinical Documentation Improvement Specialists (ACDIS) annual conference.
- At one of approximately 190 AMP Assessment Centers located around the country (click on your state for locations and directions).
Candidates who apply to take the examination will be contacted by the program when they have been approved to take the examination.
Computer testing: The CCDS examination is offered by computer at approximately 190 AMP Assessment Centers located throughout the United States (click on your state for locations and directions). There are no application deadlines and a candidate who meets eligibility requirements may submit an application and fee at any time. The examination is by appointment only Monday through Saturday at 9:00 a.m. and 1:30 p.m. Candidates are scheduled on a first-come, first served basis.
Paper-and-pencil testing: This examination is offered once annually via paper-and-pencil at the ACDIS annual conference.
CCDS examination takers will be allowed to bring the following two books with them into the test:
- DRG Expert, published by OPTUM (formerly Ingenix; 2012 and 2013 editions carry the Ingenix brand; the 2014 version carries the OPTUM Brand. All versions are accepted as an exam resource, however the most recent is suggested).
- One of the following standard drug reference guides:
- Mosby's Nursing Drug Reference
- Nurse's Pocket Drug Guide
- Physicians' Desk Reference
- PDR Nurse's Drug Handbook
- Nursing Drug Handbook/Lippincott's
Books will be checked for additional pages or loose notes inserted or attached inside. These are not allowed to be brought into the exam.
Pass/fail statistics for the CCDS exam from January 2, 2013, through December 31, 2013, are as follows:
Types of examination questions
The examination is an objective, multiple-choice test consisting of 120 questions. One hundred questions will be used in computing the score. The exam questions have been 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 improvement professionals. Because the examination is an "open book" test, candidates may use reference resources in answering recall questions, as this is the manner in which clinical documentation improvement professionals frequently carry out their responsibilities.
- 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 test 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.
Certification examination content
The exam 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 Improvement 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 following is a comprehensive list of the categories selected by this process to assist candidates in preparing for the certification examination.
1. Healthcare regulations, reimbursement, and documentation requirements related to the Inpatient Prospective Payment System (IPPS)
- Demonstrate a knowledge of Medicare Severity DRGs and how they differ from CMS-DRGs.
- Demonstrate an understanding of the responsibilities of medical and clinical staff for documentation necessary for appropriate IPPS reimbursement.
- Explain how documentation impacts IPPS diagnosis and procedure reimbursement.
- Define a complication/comorbidity under the MS-DRG system.
- Define a major complication/comorbidity under the MS-DRG system.
- Explain how CMS selects certain diagnoses as a CC or MCC.
- Identify quality measures under the IPPS.
- Demonstrate how CDI specialists can assist with the collection of quality measures under the IPPS.
- Explain how documentation impacts IPPS quality measures reimbursement.
- Define case mix index and its relevance to CDI programs.
- Determine how a hospital's individual case mix index is calculated.
- Define when and how the IPPS is updated each year.
- Explain the goals and findings of the Recovery Audit Contractor (RAC) program.
- Recognize potential RAC risks.
2. Anatomy and physiology, pathophysiology, pharmacology, and medical terminology
- Explain the clinical indicators and query opportunities related to each Major Diagnostic Category (MDC)
- MDC 4 - respiratory (e.g., pneumonia, ventilator days, COPD)
- MDC 5 - circulatory systems (e.g., types of heart failure)
- MDC 8 - musculoskeletal (e.g., debridement)
- MDC 10 - endocrine (e.g., malnutrition, diabetes, dehydration)
- MDC 11 - kidney and urinary tract (e.g., renal failure)
- MDC 18 - infectious and parasitic diseases (e.g., sepsis)
- MDC 19 - mental diseases and disorders (e.g., dementia, retardation)
- MDC 25 - HIV infections (e.g., kaposi's sarcoma, PCP)
- Explain the difference between a TIA vs. CVA
- Recognize pharmaceuticals commonly used for specific diseases
- Explain which diagnoses the following drugs (and/or their generic equivalents) are commonly used to treat:
3. Medical record documentation
- Explain query opportunities to clarify the etiology of symptoms.
- Demonstrate ability to interpret medication administration record to look for query opportunities.
- Demonstrate ability to interpret laboratory results to look for query opportunities.
- Demonstrate ability to interpret radiology results to look for query opportunities.
- Demonstrate ability to analyze emergency department documentation for admitting diagnoses.
- Recognize standard medical abbreviations used by physicians.
- Demonstrate an ability to construct open-ended non-leading written queries.
- Demonstrate an ability to construct open-ended non-leading verbal (i.e., oral) queries.
- Recognize opportunities to improve documentation of palliative care
- Demonstrate appropriate places in the medical record from which diagnoses can be assigned.
- Explain which types of physician documentation (i.e., RN, PA, NP) can be used to assign diagnoses.
- Differentiate compliant from non-compliant queries.
- Explain query opportunities inherent in a patient with a history of congestive heart failure.
- Maintain current knowledge of the AHIMA practice brief, Managing an Effective Query Process
4. Healthcare facility CDI program analysis
- Demonstrate the ability to analyze an Excel spreadsheet and evaluate a CDI program's trends.
- Demonstrate the ability to create forecasting data to predict the direction of a CDI program.
- Identify differing methodologies for evaluating documentation program standards (e.g., CC/MCC capture, severity of illness, risk of mortality).
- Identify methods for measuring physician performance related to documentation.
- Demonstrate basic computer skills and basic software applications (e.g., basic Excel spreadsheet functions).
- Demonstrate an ability to identify and apply specific hospital financial data in order to measure effectiveness.
- Identify performance standards used to evaluate individual CDI specialists' performance.
- Demonstrate an ability to track and trend data to measure hospital performance over time.
- Demonstrate an ability to track and trend data to measure department-specific performance over time.
- Explain how physician documentation impacts publicly accessible Web sites and data (e.g., Leapfrog, Healthgrades).
- Demonstrate an ability to track and trend data to measure individual physician performance over time.
5. Communication skills
- Identify methods for creating physician education forms and tools.
- Demonstrate the ability to produce basic educational presentations specific for departments/services, including physicians, nurse practitioners, and administration.
- Demonstrate the ability to communicate with physicians in an effective, non-confrontational manner.
- Describe the roles and responsibilities of a documentation specialist.
- Describe the roles and responsibilities of a coder working in conjunction with a CDI program.
- Demonstrate the ability to write a compliant physician query.
- Demonstrate the ability to reconcile discrepancies between working DRG assignments assigned by CDI staff and final, coded DRGs.
- Identify situations in which verbal, personal communications with physicians are more favorable than written communication.
6. ICD-9-CM Official Guidelines for Coding and Reporting
- Explain when ICD-9-CM guidelines are updated and where to obtain official information.
- Describe situations in which queries are not appropriate (i.e., diagnosis was not evaluated/treated/monitored).
- Explain the role of Coding Clinic for ICD-9-CM for formulating queries.
- Define the principles of principal diagnosis assignment.
- Define the principles of secondary diagnosis assignment.
- Explain how to assign a correct diagnosis when two more diagnoses are coequal to admission.
- Define how discharge dispositions and the location to which the patient is transferred impacts payment.
- Define which conditions are considered hospital acquired conditions by CMS.
- Define basics of present on admission indicator assignment.
- Define how present on admission status impacts payment.
- Explain Coding Clinic for ICD-9-CM guidelines for assignment of ICD-9-CM sepsis codes.
- Explain how to assign a working DRG when a patient has multiple diagnoses in play.
7. Professionalism, ethics, and compliance
- Maintain confidentiality of the medical record and other information relevant to the practice of CDI.
- Identify initiatives that ensure DRG compliance.
- Identify areas of potential upcoding as identified by the Office of Inspector General (OIG).
- Define upcoding and its negative impact on documentation and reimbursement.
- Demonstrate what constitutes a leading query to the physician.
- Explain the proper goals and objectives of a clinical documentation program beyond reimbursement.
Management and examination services
The Association of Clinical Documentation Improvement Specialists (ACDIS) contracts with Applied Measurement Professionals, Inc., (AMP) 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.
AMP offers a full range of services, including practice analyses and development of examination specifications, psychometric guidance to committees of content experts during examination question writing, development of content, valid examination instruments, publishing, examination administration, scoring, and reporting examination results.
Applied Measurement Professionals, Inc. (AMP)
18000 West 105th Street
Olathe, KS 66061-7543
ACDIS maintains records, handles finances, and processes examination applications, certification materials, and requests for continuing education approvals.