ABOUT :
The Certified Clinical Documentation Specialist (CCDS®) credential signifies a mark of distinction for professionals in the field of clinical documentation integrity. It is designed to elevate the professional standing of clinical documentation specialists by certifying their expertise in a broad, multidisciplinary body of knowledge. This includes healthcare regulations, coding guidelines, medical record review, communication techniques, and data analysis. Achieving the CCDS® credential demonstrates mastery of the critical skills necessary to enhance the quality and accuracy of clinical documentation, which directly impacts patient care, compliance, and healthcare outcomes.
CERTIFICATION BODY : The Association of Clinical Documentation Integrity Specialists (ACDIS)
LEARNING OBJECTIVE :
The CCDS® training program is structured to equip participants with essential skills and knowledge, including:
- In-depth Knowledge of Healthcare Regulations: Understanding healthcare and coding regulations, including CMS and private payer guidelines.
- Proficiency in Medical Record Review: Mastering techniques for analyzing and interpreting medical records to enhance documentation accuracy.
- Effective Communication Skills: Developing advanced communication and physician query techniques to improve clinical documentation.
- Quality Metrics and Data Analysis: Gaining expertise in data mining, reporting functions, and CMS quality programs that impact healthcare metrics.
- Professional Integrity: Promoting ethical standards and compliance within clinical documentation practices.
EXAM INFORMATION :
- Duration: Up to 4 hours.
- Question Types: 140 multiple-choice questions, including scenario-based queries.
- Purpose: The exam evaluates a candidate’s competency in clinical documentation improvement, ensuring they possess the requisite knowledge and skills to excel in this specialized field.
RECERTIFICATION :
Certification is valid for two years from the date of passing the exam. To maintain the CCDS® credential, certified professionals must either:
- Recertify by Continuing Education Units (CEUs): Earn a minimum of 30 CEUs over the two-year certification cycle.
- Recertify by Exam: If CEU requirements are not met, candidates may retake the certification exam before the certification expires.
Certified professionals are encouraged to track their professional development activities and apply for recertification before the expiration date to avoid lapses in certification.
Curriculum
- 10 Sections
- 32 Lessons
- 40 Hours
Expand all sectionsCollapse all sections
- INTRODUCTION TO CLINICAL DOCUMENTATION INTEGRITY (CDI)3
- 1.0Overview of CDI: Understanding the role and significance of clinical documentation in healthcare.
- 1.1History and Evolution: Tracing the development of CDI practices and their impact on patient care and hospital operations.
- 1.2Current Trends and Future Directions: Exploring the latest advancements and emerging trends in CDI.
- HEALTHCARE AND CODING REGULATIONS4
- 2.0Inpatient Prospective Payment System (IPPS): Detailed exploration of IPPS, its impact on clinical documentation, and associated CMS regulations.
- 2.1Medical Coding Guidelines: In-depth understanding of ICD-10, CPT, and HCPCS codes; aligning documentation with coding requirements.
- 2.2Private Payer Regulations: Examining the regulations set forth by private insurers and their implications for CDI.
- 2.3Compliance and Ethical Standards: Ensuring adherence to ethical guidelines and legal requirements in clinical documentation.
- ANATOMY, PHYSIOLOGY, PHARMACOLOGY, AND PATHOPHYSIOLOGY3
- 3.0Anatomy and Physiology: Comprehensive review of human body systems and their relevance to accurate clinical documentation.
- 3.1Pharmacology: Understanding drug classifications, mechanisms of action, and their documentation in medical records.
- 3.2Pathophysiology: Identifying and documenting the underlying mechanisms of diseases and conditions.
- MEDICAL RECORD REVIEW AND ANALYSIS3
- 4.0Medical Record Components: Understanding the structure and key elements of medical records.
- 4.1Document Interpretation: Techniques for analyzing and interpreting complex medical records for accuracy and completeness.
- 4.2Identifying Documentation Gaps: Methods for detecting inconsistencies or missing information in clinical records.
- COMMUNICATION AND PHYSICIAN QUERY TECHNIQUES3
- 5.0Effective Communication Strategies: Developing communication skills to collaborate with healthcare providers effectively.
- 5.1Query Formulation: Crafting compliant and clear physician queries to clarify or improve documentation.
- 5.2Physician Engagement: Techniques for fostering positive relationships with physicians to enhance documentation quality.
- CMS QUALITY PROGRAMS AND REPORTABLE DIAGNOSES3
- 6.0CMS Quality Programs: Overview of CMS quality initiatives and their implications for clinical documentation.
- 6.1Reportable Diagnoses: Understanding which diagnoses impact quality metrics and require precise documentation.
- 6.2Performance Metrics: How CDI influences hospital quality scores, reimbursement, and patient outcomes.
- DATA MINING AND REPORTING FUNCTIONS3
- 7.0Data Collection Techniques: Strategies for gathering and analyzing data from clinical documentation.
- 7.1Benchmarking CDI Performance: Tools and methods for measuring and improving CDI program effectiveness.
- 7.2Reporting Tools: Utilizing software and tools for generating CDI reports to inform decision-making.
- CDI PROGRAM MANAGEMENT AND LEADERSHIP3
- 8.0Building and Managing a CDI Team: Roles, responsibilities, and best practices for leading a successful CDI team.
- 8.1Strategic Planning for CDI: Setting goals, developing policies, and aligning CDI initiatives with organizational objectives.
- 8.2Continuous Improvement: Techniques for ongoing assessment and enhancement of CDI processes.
- CASE STUDIES AND PRACTICAL APPLICATIONS3
- 9.0Real-World Scenarios: Analyzing and learning from real case studies to apply CDI principles in practice.
- 9.1Practical Exercises: Hands-on exercises to develop proficiency in medical record review, physician querying, and data analysis.
- 9.2Problem-Solving in CDI: Approaching complex CDI challenges and finding solutions through collaborative strategies.
- EXAM PREPARATION4
- 10.0Exam Overview: Understanding the structure and content of the CCDS® exam.
- 10.1Review Sessions: Focused review on key areas such as regulations, anatomy, and physician query techniques.
- 10.2Mock Exams: Practice tests to assess readiness and identify areas for further study.
- 10.3Study Resources: Guidance on utilizing available resources, including the CCDS® Exam Prep Guide and Boot Camps.
Requirements
- Education: A minimum of an associate degree in a healthcare-related field or equivalent professional experience.
- Work Experience: At least two years of full-time experience as a clinical documentation specialist or in a related role such as health information management, medical coding, or nursing.
- Professional Knowledge: Demonstrated proficiency in anatomy, physiology, pathophysiology, pharmacology, and medical coding practices.
Target audiences
- Clinical Documentation Specialists: Professionals currently working in CDI roles who want to validate their expertise.
- Health Information Management (HIM) Professionals: Individuals involved in medical coding, health information technology, or medical record review.
- Nurses and Physicians: Healthcare providers seeking to enhance their understanding of clinical documentation integrity and its impact on patient care.
- Compliance Officers and Quality Improvement Specialists: Professionals responsible for ensuring regulatory compliance and improving healthcare quality metrics.
- Healthcare Administrators: Leaders looking to strengthen their organization’s clinical documentation practices.