Certification

What are the benefits of the CCDS certification?

Benefits for the organization:

  • Allows the organization to identify those individuals who have demonstrated knowledge and skills that equip them to manage and run an effective clinical documentation program
  • 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 hospital quality initiatives
  • 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
  • Establishes leadership within their profession and provide physicians and clinical staff with education regarding documentation requirements
  • Emphasizes the role of the clinical documentation specialist within the health information management (HIM) arena 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
FAQ Category: 

Who administers the exam?

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.

ACDIS maintains all CCD program records, handles finances, and processes examination and re-examination applications, and the recertification processes, including requests for continuing education approval.

FAQ Category: 

What are the passing score and pass rate?

The passing score is 89 corecct out of 120 scored questions. The overall pass rate in 2015 was 74.2%.

FAQ Category: 

What is the examination content?

The examination 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.

Click this link to download a PDF of examination content topics.

FAQ Category: 

What types of questions are on the examination?

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 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 professionals.
  • 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 current examination 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.

FAQ Category: 

Are any resources allowed during the examination?

Candidates may bring the following with them into the test:

  • DRG Expert, published by OPTUM, must be and ICD-10 edition
  • 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
    • Lippincott's Nursing Drug Handbook

Books will be checked for additional pages or loose notes inserted or attached inside. These are not allowed to be brought into the examination room. Page tabs are permitted.

FAQ Category: 

How do I apply for the examination?

Download the examination application, complete it, and submit it by fax, email, or U.S. mail as instructed on the application.

FAQ Category: 

How is the examination administered?

To become a Certified Clinical Documentation Specialist (CCDS), a candidate must pass the examination. It is offered by computer at more than 200 AMP Assessment Centers located around the country (visit www.goamp.com and follow the links to find locations and directions).

Candidates who apply to take the examination will be contacted when they have been approved to take the examination.

Candidates have four months/120 days from the date their name is submitted to AMP, the examination testing company, to schedule and take their examination.

There are no application deadlines (except for the examination given at the conference) and a candidate who meets eligibility requirements may submit an application and fee at any time. The fee will not be processed until the application is approved.

FAQ Category: 

What are the benefits of the CCDS certification?

Benefits for the organization:

  • Allows the organization to identify those individuals who have demonstrated knowledge and skills that equip them to manage and run an effective clinical documentation program
  • 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 hospital quality initiatives
  • 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
  • Establishes leadership within their profession and provide physicians and clinical staff with education regarding documentation requirements
  • Emphasizes the role of the clinical documentation specialist within the health information management (HIM) arena 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
FAQ Category: 

What are the eligibility requirements?

Candidates for the CCDS designation must meet educational and work experience requirements.

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 Specialist:

  • An RN, RHIA, RHIT, MD, or DO and two (2) years of experience as a concurrent/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/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, and disease process, or the AHIMA CCS credential, and a minimum of three (3) years of experience in the role as a concurrent/retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.

*Years of experience is defined as full time employment or greater than 2,000 hours/year

What is a concurrent documentation specialist?

The concurrent documentation specialist:

  • Reviews medical records daily and in the current time, while the patient is hospitalized
  • 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 that reflect severity of illness, complexity, and acuity to 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

What is a retrospective documentation specialist?

The retrospective documentation specialist:

  • Daily reviews medical records of post discharge, pre-bill records
  • Works collaboratively using real-time conversation with physicians and medical team members who cared 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 that reflect severity of illness, complexity, and acuity to 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

Equivalent foreign medical graduate experience documenting in a medical record as a clinician or resident does not meet the experience requirement.

FAQ Category: 

Membership

Setting Forum Notifications

  1. Login to ACDIS
  2. Go to the forums
  3. Click “My Profile” under the person icon on the right
  4. Click the blue “preferences” link at the top of the profile page
  5. Select “Notification Preferences” on the right
  6. Check off the Categories you want to receive notifications from for both discussions and comments
  7. Click “Save Preferences”
FAQ Category: 

How can I volunteer to serve on the ACDIS boards and committees?

Please visit the ACDIS Boards and Committees pages for additional details about the work our volunteer committees provide, the expectations of service, and selection processes.

FAQ Category: 

There are locks on content that I want to access. Why can’t I view this content?

The locks on the site designate that content is available only to members. Go to the Membership page to become a member.

I am a free user. How can I purchase a subscription?

To purchase a new membership, click here.

How can I renew my membership?

To renew your membership, you must call customer service at 800-650-6787.

How do I change my password?

Click on the green person button in the far right corner of the screen and select "My Account". You can update your password on this page.

FAQ Category: