The Certified Clinical Documentation Specialist (CCDS) examination is designed to test an applicant's ability to recall documentation and coding guidelines and industry regulations pertaining to clinical documentation improvement and apply that knowledge to real-life scenarios clinical documentation specialists face every day. Achieving this credential recognizes that a clinical documentation specialist possesses prerequisite educational requirements as well as proven, hands-on experience performing the function of a clinical documentation specialist.
General requirements: Candidates who apply for the examination must list their documentation specialist experience. Applications may be audited to verify work history and educational background.
- Candidates must have at least two years of experience as a documentation specialist experience or equivalent.
- Once a candidate has accumulated the time, it does not expire.
- All work experience must be met at the time the application is submitted
- Candidates applying for the examination will be required to list their documentation specialist experience. Applications may be audited to verify work history.
- Experience documenting in a medical record as a clinician, resident or equivalent foreign medical graduate does not meet the experience requirement.
Candidates must demonstrate that they meet one of the following requirements:
- An RHIA®, RHIT®, CCS®, CCS-P®, RN, MD or DO and two (2) years experience as a concurrent documentation specialist.
- An Associate’s degree (or equivalent education) in an allied health field and three (3) years of experience as a concurrent documentation specialist. The education component must include completed coursework in medical terminology and anatomy and physiology.
- Formal education (accredited, college-level course work) in human anatomy and/or physiology, plus medical terminology, and disease processes, and a minimum three (3) years experience as a concurrent documentation specialist.
The following requirements will be effective June 1, 2016:
The candidate for the Certified Clinical Documentation Specialist (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 Improvement Specialist:
- An RN, RHIA, RHIT, MD or DO and two (2) years of experience as a concurrent or 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 or 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, medical terminology, and disease process, or the AHIMA CCS or CCS-P credential, and a minimum of three (3) years of experience in the role as a concurrent or retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.
A year of experience is defined as full-time employment or greater than 2,000 hours worked during that year
What is a documentation specialist?
- The concurrent documentation specialist conducts daily reviews of medical records for patients who are currently hospitalized
- The retrospective documentation specialist reviews medical records daily of post discharge, pre-bill records
Both concurrent and retrospective documentation specialists also:
- 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 to ensure proper reflection of severity of illness, complexity, and acuity and 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
Please direct questions to Penny Richards.
The goal of recertification is to assure continuing competence of each CCDS and maintain the standard of professionalism in clinical documentation improvement. Those applicants who become a CCDS will be eligible for recertification every two years for a $200 fee ($100 for ACDIS members). Additionally, 30 CEUs are required. Recertification does not require a CCDS to retake the certification examination.
Continuing education hours will consist of activities including, but not limited to, the following areas:
- Listening to audio conferences
- Submitting article summaries
- Attending annual conferences
- Taking e-learning courses
For more information or to submit your CEUs for recertification, please visit our recertification page.