CCDS - Certified Clinical Documentation Specialist

Certified Clinical Documentation Specialists are experienced RNs with specialized training to facilitate the precise representation of a patient’s clinical status that then translates into accurately coded data.

The Certified Clinical Documentation Specialist (CCDS) certification is accredited by the Association of Clinical Documentation Integrity Specialists (ACDIS).

CDIS nurses work within Clinical Documentation Integrity (CDI) programs in both inpatient and outpatient care settings. These programs ensure consistency of documentation among medical staff that is then translated into improved quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

Cost

The fee for ACDIS members is currently $280 and $380 for non-members. There is an additional $100 fee for international candidates.

The CCDS program is designed to provide special recognition to those clinical documentation specialists who have a wide body of knowledge and skills in healthcare and coding regulations, anatomy, physiology, pharmacology, and pathophysiology. They apply those skills to reviewing medical records and effectively communicating and conducting physician queries as needed. 

Candidates who apply must meet one of the following three requirements:

1. Be an RN RHIA, RHIT, MD, or DO with two years of experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility.

2. An Associates degree (or equivalent) in an allied health field other than those listed above, and three years experience as a concurrent or retrospective documentation specialist in an inpatient acute care facility. The education component must include college-level coursework in medical terminology and human anatomy and physiology.

3. Formal education (accredited college-level course work) in human anatomy and physiology, medical terminology, and disease process or the AHIMA CCS or CCS-P credential, and a minimum of three years’ experience in the role as a concurrent or retrospective documentation specialist in an inpatient acute care facility. 

Once eligibility is confirmed, candidates may register for the examination.

CCDS holders must recertify every two years. This is important to ensure that CDI professionals stay abreast of changing government and private payer regulations, documentation, and coding requirements. These change frequently. 

Those applying for recertification must do so online by: 

Supplying proof of having earned 30 CEUs relevant to the CDI field. 20 of those hours can be from ACDIS, and the other 10 may be from another accrediting body such as AHIMA or ANCC.

Renewal Fees

The fee for ACDIS members is currently $125 and $225 for non-members.

The ACDIS offers resources for exam candidates, including:

• Candidate Handbook

• Free Webinar

The ACDIS also offers the Certified Clinical Documentation Specialist-Outpatient (CCDS-O).

• Home Care Clinical Specialist (HCS-O)

• Homecare Coding Specialist-Diagnosis (HCS-D)

• Certificate for OASIS Specialist - Clinical (COS-C)