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Clinical documentation specialists understand a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; an ability to analyze and interpret medical record documentation and formulate appropriate physician queries; and an ability to benchmark and analyze clinical documentation program performance.

The Certified Clinical Documentation Specialist (CCDS) credential provides a mark of distinction for this unique profession. Applicants who pass the certifying exam receive the designation.