What are the eligibility requirements for the CCDS?
Candidates for the Certified Clinical Documentation Specialist (CCDS) designation must meet educational and work experience requirements. To read a complete breakdown of the requirements, download the Exam Candidate Handbook by clicking here.
The candidate for the 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.
Interested in learning more about the certification process? Watch this free webinar with two of ACDIS' expert CDI education specialists on the topic!