A Note from the CCDS Coordinator: New CCDS exam eligibility requirements take effect June 1

by Penny Richards

ACDIS announces several changes in eligibility requirements for candidates wishing to sit for the Certified Clinical Documentation Specialist (CCDS) exam. Highlights of the changes are:

• Retrospective documentation experience is accepted in addition to concurrent documentation experience
• Individuals holding the CCS or CCS-P credential must demonstrate a minimum of three years of experience
• Experience must be from work performed in an inpatient acute care facility using the United States Inpatient Prospective Payment System
•  Experience documenting in a medical record as a clinician, resident, or equivalent foreign medical graduate does not qualify as clinical documentation improvement experience toward the requirement.

These changes take effect June 1, 2016.

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 Improvement Specialist:

• An RN, RHIA, RHIT, MD or DO and two (2) years of experience as a concurrent or 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 or 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. (A year of experience is defined as full-time employment or greater than 2,000 hours worked during that year)
• Formal education (accredited college-level course work) in medical terminology human anatomy and physiology, medical terminology, and disease process, or the AHIMA CCS or CCS-P credential, and a minimum of three (3) years of experience in the role as a concurrent or retrospective documentation specialist in an inpatient acute care facility using the United States IPPS system.

In addition, the new eligibility requirements clarifies concurrent and retrospective documentation specialist responsibilities as they relate to exam eligibility.

What is a concurrent documentation specialist?

• The concurrent documentation specialist:
• Conducts daily reviews of medical records for patients who are currently hospitalized
• Works collaboratively using real-time conversation with physicians and medical team members caring for the patient
• Uses 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 to ensure proper reflection of severity of illness, complexity, and acuity, and facilitates 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:

• Reviews medical records daily of post discharge, pre-bill records
• Works collaboratively using real-time conversation with physicians and medical team members who cared for the patient
• Uses 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 to ensure proper reflection of severity of illness, complexity, and acuity and 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

These changes are the result of considerations by the ACDIS CCDS Advisory Board to best represent the needs of the profession. For additional information, email Penny Richards.