A Service of

Association of Clinical Documentation

Integrity Specialists

The Clinical
Documentation
Specialist’s
Certification Exam
Candidate Handbook
CCDS and CCDS-O

The standard of excellence for

clinical documentation specialists
by clinical documentation specialists

2020
Candidate
Handbook
 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

About the Association of Clinical

Association of Clinical Documentation
Integrity Specialists Documentation Integrity Specialists

The Association of Clinical Documentation Integrity Specialists (ACDIS) is a diverse

community of professionals whose backgrounds include nursing, HIM/coding, physicians, case
management, quality improvement, and more. Members of ACDIS share the latest tested tips, tools,
and strategies to implement successful CDI programs and achieve professional growth. ACDIS’
mission is to bring CDI specialists together.

ACDIS offers its members a bi-monthly journal, quarterly conference calls, news updates, a forms
and tools library, a message board, a job board, and discounts on selected products. Members can
network with their colleagues and peers through member publications, working groups, local chapter
meetings, and the option of attending the ACDIS annual conference.

35 Village Road, Suite 200

Middleton, MA 01949
Tel: 877-240-6586
Fax: 978-560-0934
E-mail: [email protected]
Web site: www.acdis.org

November 2020

© 2020 HCPro, a Simplify Compliance brand | 2

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Table of Contents
About the Association of Clinical Cancellations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Documentation Integrity Specialists. . . . . . . . . . . . . . 2 CCDS Examination content. . . . . . . . . . . . . . . . . . . . . . 14
Table of Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 CCDS Examination content outline. . . . . . . . . . . . . . . 14
Note to candidates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 CCDS sample exam questions. . . . . . . . . . . . . . . . . . . 21
Mission statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 CCDS-O Examination content. . . . . . . . . . . . . . . . . . . 24
Statement of nondiscrimination. . . . . . . . . . . . . . . . . . . . 4 CCDS-O Examination content outline. . . . . . . . . . . . . 24
Clinical Documentation Specialist CCDS-O sample exam questions. . . . . . . . . . . . . . . . . 29
Certification overview. . . . . . . . . . . . . . . . . . . . . . . . . 4 On the day of your examination. . . . . . . . . . . . . . . . . . 29
CCDS Certification eligibility requirements. . . . . . . . . . 5 Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
CCDS-O Certification eligibility requirements. . . . . . . 6 Personal Belongings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
CCDS exam allowable resources. . . . . . . . . . . . . . . . . . 7 Examination Restrictions. . . . . . . . . . . . . . . . . . . . . . . . 31
CCDS-O exam allowable resources. . . . . . . . . . . . . . . . 8 Misconduct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
About the certification examinations. . . . . . . . . . . . . . . 8 Practice examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Examination fees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Timed examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
How to prepare for your CCDS examination. . . . . . . . 9 Following the examination. . . . . . . . . . . . . . . . . . . . . . . 32
How to prepare for your CCDS-O exam. . . . . . . . . . . 9 If you pass the examination. . . . . . . . . . . . . . . . . . . . . . 33
Management and examination services. . . . . . . . . . . . 10 If you do not pass the examination. . . . . . . . . . . . . . . . 33
Assessment Center locations. . . . . . . . . . . . . . . . . . . . . 10 Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Applying for the examinations. . . . . . . . . . . . . . . . . . . . 11 Scores cancelled by ACDIS or PSI. . . . . . . . . . . . . . . . . 34
Eligibility period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Copyrighted examination questions. . . . . . . . . . . . . . . 34
Scheduling an examination appointment. . . . . . . . . . . 12 Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Special arrangements for candidates Duplicate score report. . . . . . . . . . . . . . . . . . . . . . . . . . 35
with disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Recertification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Examination and appointment changes. . . . . . . . . . . . 13 Certification maintenance fees . . . . . . . . . . . . . . . . . . . 36
Missed appointments . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Failure to renew. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Inclement weather/power failure/ Disciplinary policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
other emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Contact us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

© 2020 HCPro, a Simplify Compliance brand | 3

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Note to candidates
It is your responsibility to read and understand the contents of this handbook before applying for
certification.

This handbook contains current information about the criteria and process for applying to earn the
ACDIS certifications Certified Clinical Documentation Specialist (CCDS) and Certified
Clinical Documentation Specialist - Outpatient (CCDS-O). Please refer to the
contents of this handbook for any questions you may have regarding the certification programs.

Additional information is available at the ACDIS Web site at www.acdis.org. If you cannot find the
information you require or have further questions, you may also contact:

Customer Care
[email protected]
or call ACDIS Customer Service at 877-240-6586

Mission statement
The mission of the CCDS and CCDS-O credentials is to elevate the professional standing of clinical
documentation specialists. The program draws from experienced clinical documentation specialists in
the field to establish criteria for competency in the broad and multidisciplinary bodies of knowledge
clinical documentation specialists must know. These include knowledge of healthcare and coding
regulations; anatomy, physiology, pharmacology, and pathophysiology; proficiency in medical record
review; communication and physician query techniques; relevant regulatory policy and payment
methodologies, and data mining and reporting functions.

Statement of nondiscrimination
The opportunity to become a CCDS and/or a CCDS-O is available to all eligible candidates who
meet the exam pre-qualifications as identified in the handbook. ACDIS does not discriminate on the
basis of age, gender, race, religion, national origin, marital status, sexual preference, or disability.

If special accommodations are required for the examination, notify the program at 800-650-6787.

Clinical Documentation Specialist Certification overview

The purpose of becoming a CCDS and or a CCDS-O is to recognize that those individuals who
perform the role of a clinical documentation specialist and who have a diverse set of concurrent,
prospective, and retrospective medical record review skills, clinical knowledge, and knowledge of
documentation, coding, and reimbursement rules and regulations.

© 2020 HCPro, a Simplify Compliance brand | 4

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Because the credentials were developed to recognize individuals with a proven ability to work as a
clinical documentation specialist, candidates for the CCDS and or CCDS-O designation are required
to have at least two years of experience in the profession. Additionally, candidates must have some
college-level education (see “Certification eligibility requirements” below.)

Successful candidates must achieve a passing score on the certification examination, which tests the
candidate’s ability to abide by documentation and coding regulations and apply his or her experience
and knowledge to typical scenarios that clinical documentation specialists encounter in their profession.

The certification programs are not designed to determine who shall serve as a clinical documentation
specialist. That is the responsibility of the leadership team for each hospital. Instead, the goal is to
establish a baseline of competency in professionals who serve as clinical documentation specialists, be
they from nursing, HIM/coding, physician/provider, or other healthcare-related backgrounds.

The certification programs are a service provided in conjunction with ACDIS specifically to help
those professionals with baseline levels of education and experience as a clinical documentation
specialist achieve a mark of distinction and professionalism. The required experience and education
ensure that only clinical documentation specialists with proven ability to perform their functions can
achieve this certification.

CCDS Certification eligibility requirements

Candidates for the CCDS exam must meet one of the following three education and experience
standards and currently be employed as either a concurrent or retrospective Clinical Documentation
Integrity Specialist:
Ü 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.
Ü 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.
Ü 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.

© 2020 HCPro, a Simplify Compliance brand | 5

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

A year of experience is defined as full-time employment or greater than 2,000 hours worked during
that year.

Experience documenting in a medical record as a clinician, resident or equivalent foreign medical

graduate does not meet the experience requirement.

What is a documentation specialist?

Ü The concurrent documentation specialist conducts daily reviews of medical records for
patients who are currently hospitalized or treated in the outpatient arena
Ü The retrospective documentation specialist reviews medical records daily of post discharge,
pre-bill records

Both concurrent and retrospective documentation specialists also:

Ü Work collaboratively using real-time conversation with physicians and medical team mem-
bers caring for the patient
Ü Use their 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
Ü Communicate with providers, whether in verbal discussion or by query, for missing,
unclear or conflicting documentation
Ü Educate providers about optimal documentation, identification of disease processes to ensure
proper reflection of severity of illness, complexity, and acuity and facilitate accurate coding

CCDS-O Certification eligibility requirements

Candidates for the CCDS exam must meet one of the following two education and experience
standards:
Ü An RN, MD, DO or coding certification (RHIA, RHIT, CCS, CPC, CRC, COC) and two
(2) years of experience as an outpatient documentation specialist using United States
reimbursement systems.
Ü An RN, MD, DO) or coding certification (RHIA, RHIT, CCS, CPC, CRC, COC), one (1) year
of experience as an inpatient clinical documentation specialist, and one (1) year of experience
as an outpatient documentation specialist using United States reimbursement systems.

© 2020 HCPro, a Simplify Compliance brand | 6

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

A year of experience is defined as full-time employment or greater than 2,000 hours worked during
that year.

Experience documenting in a medical record as a clinician, resident or equivalent foreign medical

graduate does not meet the experience requirement.

What is an outpatient documentation specialist?

These functions define the role of an outpatient documentation specialist:
Ü Conducts reviews of medical records for patients in a variety of outpatient settings including
but not limited to physician offices, physician and hospital-owned clinics, ambulatory surgery
centers, and hospital emergency departments.
Ü Collaborates with physicians and medical team members caring for the patient to clarify
clinical documentation
Ü Applies their clinical knowledge to evaluate how the medical record will translate into coded
data, including reviewing provider and other clinical documentation, chronic disease process-
es, medications and their indications, diagnostic information, and treatment plans
Ü Communicates with providers, whether in verbal discussion or by query, for missing, unclear
or conflicting documentation
Ü Educates providers about optimal documentation and identification of disease processes to
ensure proper reflection of severity of illness, complexity, and acuity, and facilitate accurate
coding and billing
Ü Understands risk adjusted payment methodologies, professional coding and billing, and
outpatient facility coding and billing, and share this knowledge with providers and members
of the healthcare team

CCDS exam allowable resources

Examination takers for the CCDS are allowed to bring the following two resources with them into
the examination:
Ü DRG Expert, published by OPTUM (the 2019 edition is published in two volumes)
Ü One of the following standard drug reference guides:
– Nursing Drug Handbook/Lippincott’s – Pearson’s Nurse’s Drug Guide
– Mosby’s Nursing Drug Reference – Saunders Nursing Drug Handbook
– Physicians’ Desk Reference – Davis’s Drug Guide
(or PDR Nurse’s Drug Handbook)

© 2020 HCPro, a Simplify Compliance brand | 7

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Books will be checked for additional pages or loose notes inserted or attached inside. These are not allowed to
be brought into the testing room. Tabs are permitted in books as are handwritten notes previously written in
the margins of books are permitted. Candidates may not write in their books during the exam.

CCDS-O exam allowable resources

Examination takers for the CCDS-O are allowed to bring one of the following standard drug reference
guides with them into the examination:
Ü Nursing Drug Handbook/Lippincott’s
Ü Mosby’s Nursing Drug Reference
Ü Physicians’ Desk Reference (or PDR Nurse’s Drug Handbook)
Ü Pearson’s Nurse’s Drug Guide
Ü Saunders Nursing Drug Handbook
Ü Davis’s Drug Guide

Books will be checked for additional pages or loose notes inserted or attached inside. These are not
allowed to be brought into the testing room. Tabs are permitted in books as are handwritten notes
previously written in the margins of books. Candidates may not write in their books during the exam.

About the certification examinations

To become a CCDS and or a CCDS-O, a candidate must pass an examination. Examinations are offered
by computer at approximately 300 PSI Assessment Centers located throughout the United States.
Applications from those who meet eligibility requirements are accepted on a rolling basis; there are no
deadlines for exam applications and the associated fees.

The examination is administered by appointment Monday through Saturday. Candidates are scheduled on
a first-come, first-serve basis. The examination is not offered on the following holidays:
Ü New Year’s Day Ü Labor Day

Ü Martin Luther King Day Ü Thanksgiving (and the following Friday)

Ü Memorial Day Ü Christmas Eve Day

Ü Independence Day (July 4) Ü Christmas Day

Examination fees
The fee for the certification application process and examination is $255 for ACDIS members and $355
for non-members. Payment may be made by credit card, personal check, or money order for the total
amount, payable to HCPro or ACDIS. All fees are non-refundable.

© 2020 HCPro, a Simplify Compliance brand | 8

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

If you do not pass the exam, you may submit the re-exam application to schedule a new exam (see
“Applying for the examination” on p. 11 of the handbook). ACDIS will discount the exam fee to $125
for one retake only. Subsequent attempts to pass the exam will be at full price ($355 or $255 for
ACDIS members). There is a mandatory ninety (90) day waiting period between exam attempts.

How to prepare for your CCDS examination

As a CCDS candidate, it is your responsibility to be aware of the first-time exam takers’ passing
percent—presently about 77%, which means that 23% of exam takers do not pass on their first
attempt. Many of these candidates are veteran, knowledgeable, savvy CDS professionals. Not passing
the exam is not an indicating of failing. Failing occurs when you decide not to try again.

We strongly suggest that you:

Ü Read the Exam Candidate’s Handbook
Ü Understand how to use the allowed resources
Ü Know the eight specific areas of exam content
Ü Review the core competencies within the area of exam content and ask a peer or mentor
for assistance with those areas in which you may not have experience
Ü Read the ACDIS Code of Ethics, Official Guidelines for Coding and Reporting, and the
AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice
Ü Understand that the CCDS Exam Study Guide and accompanying practice exam are study
guides and not blueprints for the exam

It is the candidate’s responsibility to prepare for the exam and understand that some of the exam
questions may assess knowledge and skill you do not apply in your role.

How to prepare for your CCDS-O exam

We strongly suggest that you:
Ü Read the Exam Candidate’s Handbook
Ü Know the five specific areas of exam content
Ü Review the recommended sources of study
Ü Review the core competencies within the area of exam content and ask a peer or mentor
for assistance with those areas in which you may not have experience

© 2020 HCPro, a Simplify Compliance brand | 9

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Read the ACDIS Code of Ethics, Official Guidelines for Coding and Reporting, the AHIMA/
ACDIS guidelines for Achieving a Compliant Query Practice, and Queries in Outpatient
CDI: Developing a Compliant, Effective Process
Ü Understand that the CCDS-O Exam Study Guide and accompanying practice exam are
study guides and not blueprints for the exam

It is the candidate’s responsibility to prepare for the exam and understand that some of the exam
questions may assess knowledge and skill you do not apply in your role.

Management and examination services

ACDIS contracts with PSI to provide management and examination services. PSI provides administrative
support for the certification process, including examination development, validation, and administration.
PSI carefully adheres to industry standards for development of practice-related, criterion-referenced
examinations to assess competency. PSI offers a full range of services, including practice analyses and
development of examination specifications, psychometric guidance to committees of content experts
during examination question writing, development of content, valid examination instruments, publishing,
examination administration, scoring, and reporting examination results.

PSI
18000 West 105th Street
Olathe, KS 66061-7543
Tel: (855) 579-4641
Web site: schedule.psiexams.com

ACDIS maintains records, handles finances, and processes examination applications, certification
materials, and requests for continuing education approvals.

© 2020 HCPro, a Simplify Compliance brand | 10

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Assessment Center locations

A current list of Assessment Centers is available at schedule.psiexams.com. Specific address informa-
tion will be provided when a candidate schedules an examination appointment.

Applying for the examinations

All candidates may review the application process on the ACDIS Web site at www.acdis.org.

Candidates for certification must list their clinical documentation specialist experience. Applications
may be audited to verify work history and educational background, credentials, and licensure. Once a
candidate has accumulated the time as a clinical documentation specialist, it does not expire for the
purposes of applying for certification.

Candidates must meet all required work and education requirements must be met prior to
submitting and application.

To apply, complete the online examination application, which is available online at www.acdis.org in
the Certification “How to Apply” section. Once you click the online application link, login using your
ACDIS credentials, or create a new login to complete the online application. You will have the
opportunity to save a draft and return to the online application if you are unable to complete it in
one sitting. Credit card payment is required in order to submit the application.

For questions, please contact Customer Service via email [email protected] or call 877-240-6586.

ACDIS and HCPro will process the application and send a receipt confirmation to the candidate.
Upon approval the candidate’s name will be send to the exam company, PSI and they will send the
candidate instructions about how to schedule an exam appointment.

Eligibility period
A candidate’s application is valid for 90 days (3 months) from the date the name is submitted to the
exam company, during which the candidate must schedule an appointment to test on the computer
and take the examination.

A candidate who fails to take the exam within the eligibility period forfeits the application and all fees
paid to take the examination. A completer re-examination application and examination fee are
required to reapply for examination. A candidate is allowed to take only the examination for which
application is made and a confirmation notice is received. Unscheduled candidates (walk-ins) are not
eligible to take the exam.

© 2020 HCPro, a Simplify Compliance brand | 11

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Scheduling an examination appointment

After you have registered for the examination and received notification of your eligibility by e-mail
and/or letter, you may schedule the examination online or by phone.

Schedule online: Schedule a testing appointment online at any time by using PSI’s Online Application/
Scheduling service at schedule.psiexams.com. To use this service, go to schedule.psiexams.com and select
the “Candidates” section. Follow the simple step-by-step instructions to choose your examination
program and register for the examination.

Schedule by phone: Call PSI toll-free at (855) 579-4641 to schedule an examination appointment from
7 a.m. – 9 p.m. (Central Time) Monday through Thursday, 7 a.m. to 7 p.m. on Fridays, and
8:30 a.m. to 5 p.m. on Saturdays.

When you contact PSI to schedule an appointment, please be prepared to confirm a date and
___location for testing and to provide your name and CD candidate number (from PSI’s email scheduling
notice). Note: Your Social Security number is required for unique identification. All individuals are
scheduled on a first-come, first-served basis.

You will be notified of the time to report to the assessment center. Please make a note of it since you
will not receive an admission letter. Unscheduled candidates (walk-ins) will not be admitted to the
assessment center.

Special arrangements for candidates with disabilities

PSI is interested in ensuring that no individual with a disability is deprived of the opportunity to take
the examination solely by reason of that disability. PSI will provide reasonable accommodations for
candidates with disabilities.

Verification of the disability and a statement of the specific type of assistance needed must be made
in writing to PSI at least 45 calendar days prior to your desired examination date.

Download and complete the Request for Special Accommodations (found on the ACDIS web site on
the “How to Apply” pages under the “Certification” tab). Submit it to ACDIS with your exam
application. PSI will review the submitted forms and will contact you regarding the decision for
accommodations.
Ü Wheelchair access is available at all established assessment centers. Candidates must advise
PSI at the time of registration that wheelchair access is necessary.
Ü Candidates with visual, sensory, or physical disabilities that would prevent them from taking
the examination under standard conditions may request special accommodations and
arrangements.

© 2020 HCPro, a Simplify Compliance brand | 12

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Examination and appointment changes

Candidates may reschedule their appointment for a future date on one occasion per examination fee
paid. Candidates who wish to change their appointments must call PSI at (855) 579-4641 at least two
business days prior to the examination. Candidates who wish to change their appointments within
two days of the examination will not be refunded their examination fee and will be required to pay
the entire examination fee for any future examinations.

Missed appointments
A candidate will forfeit the examination registration and all fees paid under the following circumstances:
Ü The candidate wishes to reschedule an examination but fails to contact PSI at least two
business days prior to the scheduled testing session
Ü The candidate wishes to reschedule a second time
Ü The candidate appears more than 15 minutes late for an examination
Ü The candidate fails to report for an examination appointment

Inclement weather/power failure/other emergency

In the event of inclement weather or unforeseen emergencies on the day of an examination, PSI will
determine whether circumstances warrant the cancellation, and subsequent rescheduling, of an
examination. The examination will usually not be rescheduled if the Assessment Center personnel are
able to open the Assessment Center.

You may visit PSI’s website at schedule.psiexams.com prior to the examination to determine if PSI has
been advised that any Assessment Centers are closed. Every attempt is made to administer the
examination as scheduled; however, should an examination be canceled at an Assessment Center, all
scheduled candidates will receive notification following the examination regarding rescheduling or
reapplication procedures.

For computer-based examinations, if power to an Assessment Center is temporarily interrupted

during an administration, your examination will be restarted. The responses provided up to the point
of interruption will be intact, but for security reasons the questions will be scrambled.

© 2020 HCPro, a Simplify Compliance brand | 13

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Cancellations
Candidates who fail to arrive at the assessment center on the date and time they are scheduled for
examination will not be refunded any portion of their examination fees and must reregister; examination
fees may not be transferred to another appointment. Candidates who arrive more than 15 minutes late for
an appointment will not be admitted, will forfeit their examination fee, and must reregister.

CCDS Examination content

The CCDS examination is based upon eight major content areas. Each of the content areas is briefly
described and followed by an outline of the topics included in the area. In addition, the number of
examination questions devoted to each major content area is noted.

The examination is composed of 140 multiple-choice questions.

Each question on the examination is categorized by a cognitive level that a candidate would likely use
to respond. These categories are:
Ü Recall: The ability to recall or recognize specific information
Ü Application: The ability to comprehend, relate, or apply knowledge to new or changing
situations
Ü Analysis: The ability to analyze and synthesize information, determine solutions, and/or
evaluate the usefulness of a solution

The test is designed to contain approximately 30% recall questions, 40% application questions, and
30% analysis questions.

CCDS Examination content outline

The CCDS exam covers the following core competencies:

Healthcare regulations, reimbursement, and documentation requirements related to the

IPPS: 15 items (Recall 10, application 3, analysis 2)
Ü Define the IPPS and the process by which it is updated and revised
Ü Demonstrate a knowledge of Medicare Severity Diagnostic Related Groups (MS-DRGs)
Ü Demonstrate an understanding of the responsibilities of medical staff (i.e., providers) and
clinical staff for documentation necessary for appropriate IPPS reimbursement
Ü Explain how documentation impacts reimbursement under the IPPS though diagnosis and
procedure assignment.

© 2020 HCPro, a Simplify Compliance brand | 14

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Explain the relationship between documentation and medical necessity of setting

– Demonstrate an understanding of criteria to support an inpatient admission (i.e., CMS
2-Midnight Rule)
– Demonstrate an understanding of the relationship between principal diagnosis assignment
and medical necessity of setting
Ü Define and recognize a complication/comorbidity under the MS-DRG system.
Ü Define and recognize a major complication/comorbidity under the MS-DRG system
Ü Define case mix index and its relevance to CDI programs
Ü Explain the role of Medicare Contractors, including Recovery Auditors (RA), Medicare
Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) contractors,
and the Office of Inspector General (OIG), and their impact on CDI efforts.
Ü Recognize coding and billing practices that are vulnerable to denial.

Anatomy and physiology, pathophysiology, pharmacology, and medical terminology:

23 items (Recall 0, Application 12, Analysis 11)
Ü Identify and apply clinical indicators and query opportunities typically targeted by CDI
professionals related to common medical conditions, such as those listed below by Major
Diagnostic Category (MDC):
– MDC 1– Diseases and Disorders of the Nervous System. Examples include: acute CVA,
encephalopathy, seizures, cerebral edema, coma
– MDC 4 – Diseases and Disorders of the Respiratory System. Examples include: pulmonary
embolism, respiratory neoplasms, pleural effusions, COPD, respiratory infections,
pneumonia, respiratory failure (acute/chronic), ventilation support.
– MDC 5 – Diseases and Disorders of the Circulatory System. Examples include: acute
myocardial infarction, heart failure, hypertension, cardiac arrhythmia, syncope and collapse,
angina pectoris, chest pain.
– MDC 6 – Diseases and Disorders of the Digestive System. Examples include: esophageal
disorders, peritoneal infections, digestive malignancy, GI hemorrhage, ulcer, obstruction.
– MDC 7 – Diseases and Disorders of the Hepatobiliary System. Examples include: cirrhosis,
hepatitis, malignancy, pancreatic disorders, disorders of the liver and the biliary tract.
– MDC 8 – Diseases and Disorders of the Musculoskeletal system. Examples include:
Fractures, osteomyelitis, bone diseases.

© 2020 HCPro, a Simplify Compliance brand | 15

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

– MDC 9 – Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast. Examples
include: debridement procedures, skin ulcers, malignant disorders, cellulitis, trauma.
– MDC 10 – Endocrine, Nutritional and Metabolic Disease and Disorders. Examples include:
Diabetes, dehydration, obesity, malnutrition.
– MDC 11 – Diseases and Disorders of the Kidney and Urinary Tract. Examples include: renal
failure (acute/chronic), urinary tract infections, urosepsis, urinary stones.
– MDC 16 – Diseases and Disorders of the Blood and Blood Forming Organs and
Immunological Disorders. Examples include: Red blood cell disorders- anemia, coagulation
disorders, sickle cell disease.
– MDC 17 – Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms.
Examples include: Lymphoma, leukemia, neoplasms.
– MDC 18 – Infectious and Parasitic Diseases. Examples include: postoperative infections,
bacterial infections, viral infections, sepsis.
– MDC 19 – Mental Diseases and Disorders. Examples include: psychoses, developmental
disorders, dementia, behavioral disorders.
– MDC 20 – Alcohol/Drug Use and Alcohol/Drug Induced Organic Brain Disorders.
Examples include: alcohol/drug abuse, dependence
– MDC 21 – Injuries, Poisonings and Toxic Effects of Drugs. Examples include: traumatic
injuries, poisoning and toxic effects of drugs, complications of treatment, adverse reactions.
– MDC 25 – HIV Infections. Examples include: HIV related and major related conditions as
differentiate within the DRG Expert.
Ü Recognize pharmaceuticals commonly used in the inpatient setting and the disease process
(es) they treat.
Ü Demonstrate ability to interpret medications as a clinical indicator.
Ü Identify diagnostic tests (e.g., labs, radiology, etc.) as possible clinical indicators to support
documentation clarification opportunities
Ü Recognize standard medical abbreviations used in the healthcare setting.

© 2020 HCPro, a Simplify Compliance brand | 16

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Medical record documentation: 23 items (Recall: 6, Application 11, Analysis 6)

Ü Explain which elements of the health record can be used for diagnosis and/or procedure
code assignment.
Ü Explain how the role of the provider in relation to the patient (i.e., attending physician vs.
radiologist, pathologist, or other) affects diagnosis code assignment.
Ü Identify documentation in need of clarification for accurate code assignment.
Ü Demonstrate an understanding of when a physician query is warranted.
Ü Explain the different types of physician queries (i.e., concurrent, retrospective, verbal, etc.)
Ü Demonstrate an understanding of the different physician query formats (i.e., open ended,
multiple choice, and yes/no) and their proper application.
Ü Define the concept of clinical indicator(s).
Ü Demonstrate an understanding of how to translate clinical indicators in the health record
(i.e., laboratory results, imaging reports, orders, etc.) into a compliant query
Ü Differentiate compliant from non-compliant queries.
Ü Describe situations in which queries are not appropriate (i.e., diagnosis was not evaluated/
treated/monitored, etc.).
Ü Demonstrate an understanding of current professional guidance including the AHIMA-ACDIS
practice brief, Guidelines for Achieving a Compliant Query Practice.
Ü Explain proper mechanisms to address diagnoses in the medical record without clinical support.

Healthcare facility CDI program analysis: 10 items (Recall 3, Application 4, Analysis 3)

Ü Demonstrate the ability to analyze data and evaluate a CDI program’s trends.
– CDI specialist productivity metrics
– Provider response rates
– Case mix index (CMI)
Ü Demonstrate the ability to create forecasting data to predict the direction of a CDI
program.

© 2020 HCPro, a Simplify Compliance brand | 17

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Recognize the importance of the following metrics/methodologies for evaluating CDI

program performance:
– CMI
– CC/MCC capture
– Severity of Illness/Risk of Mortality
– Hospital Value Based Purchasing measures
– Patient Safety Indicators
– Monitoring of high frequency DRGs
Ü Identify methods for measuring physician performance related to documentation
Ü Demonstrate an ability to track and trend data to measure individual physician performance
over time
Ü Demonstrate basic computer skills and basic software applications (e.g., basic Excel
spreadsheet functions)
Ü Demonstrate an ability to identify and apply hospital specific financial data.
Ü Identify performance standards used to evaluate individual CDI specialists’ performance.
Ü Demonstrate an ability to track and trend data to measure hospital performance over time
Ü Demonstrate an ability to track and trend data to measure department-specific performance
over time
Ü Explain how physician documentation impacts publicly reported data (e.g., Leapfrog, Healthgrades)
Ü Demonstrate a working knowledge of a PEPPER (Program for Evaluating Payment Patterns
Electronic Report) data

Communication skills: 11 items (Recall: 3, Application 6, Analysis 2)

Ü Identify methods for creating physician education forms and tools.
Ü Demonstrate the ability to produce basic educational presentations specific for depart-
ments/services, including physicians, nurse practitioners, and administration.
Ü Demonstrate the ability to communicate with physicians in an effective, non-confrontational
manner
Ü Describe the roles and responsibilities of a documentation specialist.
Ü Describe the roles and responsibilities of a coder working in conjunction with a CDI
department

© 2020 HCPro, a Simplify Compliance brand | 18

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Demonstrate the ability to reconcile discrepancies between working DRG assignments

assigned by CDI staff and final, coded DRGs
Ü Identify situations in which verbal, personal communications with physicians are more
favorable than written communication

Official Guidelines for Coding and Reporting: 17 items (Recall 6, Application 8, Analysis 3)
Ü Explain when Official Guidelines for Coding and Reporting are updated and where to
obtain official information
Ü Explain the role of AHA Coding Clinic in code assignment.
Ü Define and apply the principles of principal diagnosis assignment.
Ü Apply coding guidelines when selecting a principal diagnosis.
Ü Define and apply the principles of secondary diagnosis assignment.
Ü Explain how discharge dispositions and the ___location to which the patient is transferred
impact payment.
Ü Identify which conditions are considered hospital acquired conditions by CMS.
Ü Define the basics of the present on admission indicator assignment and explain its impact
on payment
Ü Explain how to assign a working DRG when a patient has multiple diagnoses in play

Professionalism, ethics, and compliance: 11 items (Recall 4, Application 4, Analysis 3)

Ü Maintain confidentiality of the medical record and other information relevant to the
practice of CDI
Ü Identify initiatives that ensure DRG compliance
Ü Identify areas of potential DRG creep as identified by the Office of Inspector General (OIG).
Ü Demonstrate what constitutes a leading query to the physician
Ü Explain the goals and objectives of a clinical documentation department beyond
reimbursement
Ü Identify potential compliance risks identified in a PEPPER report

© 2020 HCPro, a Simplify Compliance brand | 19

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Impact of Reportable Diagnoses on Quality of Care: 10 items Recall: 3, Application

3, Analysis 4)

Ü Demonstrate knowledge of the significance of documentation and code assignment upon

mortality index (Severity of Illness/Risk of Mortality)
Ü Demonstrate knowledge of mortality reviews and interpreting observed/ expected ratios
Ü Define how quality data is acquired through both record abstraction and claims data
Ü Explain the significance of these different types of quality metrics used by CMS:
– Hospital Value Based Purchasing (HVBP)
– Hospital Acquired Condition (HAC) Reduction Program
– Hospital Readmissions Reduction Program
– 30-day Mortality Measures
Ü Analyze the financial impact of the Hospital Inpatient Quality Reporting Program on an
organization, and the role of CDI regarding this CMS quality initiative
Ü Demonstrate an understanding of CDI impact on documentation and code assignment in
relation to Hospital Value Based Purchasing (HVBP)
Ü Identify components of Patient Safety Indicator (PSI) 90 and its impact as a quality measure:
– PSI 03—Pressure Ulcer Rate
– PSI 06—Iatrogenic Pneumothorax Rate
– PSI 08—Postoperative Hip Fracture Rate
– PSI 09—Postoperative Hemorrhage or Hematoma Rate
– PSI 10—Postoperative Acute Kidney Injury Rate
– PSI 11—Postoperative Respiratory Failure Rate
– PSI 12—Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate
– PSI 13—Postoperative Sepsis Rate
– PSI 14—Postoperative Wound Dehiscence Rate
– PSI 15—Accidental Puncture or Laceration Rate
Ü Identify other Patient Safety Indicators beyond or in addition to PSI 90 and their impact as a
quality measure(s)

© 2020 HCPro, a Simplify Compliance brand | 20

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

– Identify coded data elements that can impact the reporting of Patient Safety Indicators (PSIs)
in regard to Medicare claims
– Compare and contrast Hospital Acquired Infections (HAI) from documentation that sup-
ports the assignment of a “complication code”

CCDS sample exam questions

Sample question 1: Which of the following medications is commonly prescribed to stimulate
appetite in patients with neoplasm or HIV-related cachexia?
A. Meridia®
B. Namenda®
C. Megace®
D. Synthroid®

Answer: C

Sample question 2: When there is conflicting clinical documentation in the medical record,
clarification must be provided by the
A. physician assistant
B. consulting physician
C. attending physician
D. emergency physician

Answer: C

Sample question 3: Which of the following is considered a major complication/ comorbidity (MCC)?
A. chronic obstructive pulmonary disease
B. bacteremia
C. congestive systolic heart failure
D. severe protein-calorie malnutrition

Answer: D

© 2020 HCPro, a Simplify Compliance brand | 21

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Sample question 4: A patient was admitted with shortness of breath, swelling in the lower extremi-
ties, severe weakness, elevated BNP of 1,000, and EF=25%. The patient’s history and physical includes
history of heart failure. The echocardiogram report states left ventricular dysfunction. Which of the
following should the clinical documentation specialist consider when querying the practitioner for the
appropriate documentation?
A. combined diastolic and systolic heart failure
B. congestive systolic heart failure
C. acute and chronic systolic heart failure
D. acute and chronic diastolic heart failure

Answer: C

Sample question 5: Various methods exist for measuring how well physicians participate in CDI
programs. Which of the following metrics indicates a lack of physician engagement?
A. volume of queries generated
B. volume of non-responses
C. volume of “agree” responses
D. volume of “disagree” responses

Answer: B

Sample question 6: It is important for the clinical documentation specialist to discuss a concurrent
query with the physician when

1. only part of the query is answered

2. there is conflicting documentation
3. the physician documents a probable diagnosis
4. the physician refuses to acknowledge or respond to the query
A. 1, 2, and 3 only
B. 1, 2, and 4 only
C. 1, 3, and 4 only
D. 2, 3, and 4 only

Answer: B

© 2020 HCPro, a Simplify Compliance brand | 22

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Sample question 7: Which of the following is classified by CMS as a hospital-acquired condition

(HAC) when not present on admission (POA) to the hospital?
A. Fat embolism
B. Kidney disease
C. Pneumonia
D. Fractured ulna

Answer: D

Sample question 8: Aplastic anemia is a condition that:

A. Is hereditary and can only be sequenced as the principal diagnosis
B. Is defined as bone marrow failure causing a reduction in white blood cells, red blood cells,
and platelets
C. Is chronic and easily treated
D. Qualifies as a major comorbid condition (MCC)

Answer: B

Sample question 9: If the documentation indicates that the patient was admitted with fever,
shortness of breath, chest pain, and nonproductive cough, and the chest x-ray confirms a pleural
effusion, which type of effusion is most suspicious for this patient?
A. Malignant
B. Transudative
C. Exudative
D. Serosanguinous

Answer: C

© 2020 HCPro, a Simplify Compliance brand | 23

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

CCDS-O Examination content

The CCDS-O examination is based upon five major content areas. Each of the content areas is
briefly described and followed by an outline of the topics included in the area. In addition, the num-
ber of examination questions devoted to each major content area is noted.

The examination is composed of 140 multiple-choice questions.

Each question on the examination is categorized by a cognitive level that a candidate would likely use
to respond. These categories are:
Ü Recall: The ability to recall or recognize specific information
Ü Application: The ability to comprehend, relate, or apply knowledge to new or changing
situations
Ü Analysis: The ability to analyze and synthesize information, determine solutions, and/or
evaluate the usefulness of a solution

CCDS-O Examination content outline

1. Healthcare regulations, reimbursement, and documentation requirements related to the
Official Guidelines for Coding and Reporting (OCG), the Outpatient Prospective Payment
System (OPPS), and provider coding and billing
Ü Demonstrate knowledge of the OCG for ICD-10-CM
– Identify core concepts of a first-listed diagnosis
– Identify core concepts of additional/secondary diagnoses
– Identify documentation from non-providers that can be used for code assignment, as
described in Section 1, B14 of the OCG
– Explain relevant concepts from Section I of the OCG including chapter-specific guidelines
– Identify relevant coding principles from Section IV of the OCG including uncertain diagnoses,
chronic diseases, and codes that describe signs and symptoms
– Define criteria of what constitutes a reportable diagnosis, as defined in Section IV of the
OCG including first-listed and co-existing conditions
Ü Explain the role of AHA Coding Clinic/CPT Assistant in code assignment.

© 2020 HCPro, a Simplify Compliance brand | 24

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Demonstrate knowledge of the OPPS

– Identify services covered under the OPPS
– Identify code sets used in the OPPS
– Identify methodologies used in OPPS reimbursement including Ambulatory Payment
Classifications (APC)
– Demonstrate an understanding of the responsibilities of providers and other clinical staff for
documentation necessary for appropriate OPPS reimbursement.
– Explain core concepts related to patient status, including inpatient vs. observation
Ü Explain professional billing concepts and their application, including:
– Current Procedural Terminology (CPT) codes, specifically Evaluation and Management
(E/M) and relevant CMS Documentation Guidelines, and where documentation may be
obtained from the medical record
– Understand the basic concepts of the documentation necessary for professional fee
reimbursement under the Medicare Physician Fee Schedule, including the relationship of
CPT and ICD-10-CM for medical necessity, claims submission, and reimbursement
• Unspecified diagnoses

2. Diseases and disease processes, and application to the clinical chart review
Ü Identify and apply clinical indicators and query opportunities related to common medical
conditions, abnormal findings, external causes, and other factors influencing health status, as
outlined within the Tabular List of Diseases and Injuries, including the following:
– Infectious and Parasitic Diseases (A00-B99)
– Neoplasms (C00-D49)
– Diseases of the Blood & Blood-Forming Organs and Certain Disorders Involving the
Immune Mechanism (D50-D89)
– Endocrine, Nutritional and Metabolic Diseases (E00-E89)
– Mental, Behavioral and Neurodevelopmental Disorders (F01-F99)
– Diseases of the Nervous System (G00-G99)
– Diseases of the Circulatory System (I00-I99)
– Diseases of the Respiratory System (J00-J99)
– Diseases of the Digestive System (K00-K94)

© 2020 HCPro, a Simplify Compliance brand | 25

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

– Diseases of the Skin and Subcutaneous Tissue (L00-L99)

– Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)
– Diseases of the Urinary System (N00-N99)
– Pregnancy, childbirth and the Puerperium (O00-O99)
– Certain Conditions Originating in the Perinatal Period (P00-P96)
– Congenital Malformations, Deformations and Chromosomal Abnormalities (Q00-Q99)
– Symptoms, Signs and Abnormal Clinical and Laboratory Findings (R00-R99)
– Injury, poisoning and Certain Other Consequences of External Causes (S00-T88)
– Factors Influencing Health Status and Contact with Health Services (Z00-Z99)
Ü Identify opportunities for clarification typically presented in primary care visits
Ü Demonstrate ability to perform prospective case reviews
Ü Application to case scenarios with clarification opportunities
Ü Demonstrate an ability to perform retrospective case reviews
– Application to case scenarios with clarification opportunities
Ü Recognize common pharmaceuticals and medications and the disease process(es) they treat.
Ü Identify diagnostic tests (e.g., labs, radiology, etc.), elements of consult notes, and
medications without a corresponding diagnosis, as possible clinical indicators to support
documentation clarification opportunities
Ü Recognize standard medical abbreviations used in healthcare settings.

3. Risk adjustment models and impact of documentation and coding

Ü Explain the concept of risk adjustment and its relationship to medical record documentation
– Explain health record elements that impact risk scores, beyond diagnoses
– Recognize and define common risk adjustment methodologies including those used by
Medicare, Medicaid, and commercial payers
Ü Explain fundamentals of the CMS Hierarchical Condition Category (HCC) risk adjustment
model
– Describe the principles of the Medicare Advantage program including capitated payments
– Demonstrate an understanding of Medicare risk adjustment factor (RAF) scoring, including
how RAF scores are calculated

© 2020 HCPro, a Simplify Compliance brand | 26

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

– Define the following concepts within the CMS-HCC model:

• Hierarchies
• Disease interactions
• Beneficiary demographics (community and institutional)
Ü Explain parameters and requirements of compliant CMS-HCC reporting
Ü Identify diagnoses that qualify as CMS-HCCs and risk adjust, principally outpatient but also
inpatient

4. CDI program concepts: Department metrics and provider education

Ü Demonstrate an ability to develop succinct, effective provider education
– Identify methods for creating provider education forms and tools
– Demonstrate the ability to produce basic educational presentations specific for depart-
ments/services, including providers, clinical staff, and administration
– Demonstrate the ability to communicate with providers in an effective, non-confrontational
manner
Ü Describe critical performance indicators and data elements that monitor the impact of
CDI specialist efforts, including:
– Productivity of outpatient chart reviews, query rates, and provider educational sessions
conducted
– Rates of diagnoses captured as coded data as a result of CDI intervention
Ü Demonstrate an ability to track and trend data to measure organizational performance
over time.
Ü Demonstrate the ability to analyze data and evaluate outpatient CDI department
performance, including:
– HCC reporting, including HCCs that are dropped, recaptured, and/or newly added over
prior year
– Risk adjustment factor (RAF) scoring, including progression over baseline and trending
– Accountable Care Organization (ACO) and Medicare Shared Savings Program (MSSP)
impact, including quality scores and performance payments
Ü Identify physician performance metrics, including:
– RAF scores
– E/M billing

© 2020 HCPro, a Simplify Compliance brand | 27

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

– Risk adjusted diagnosis capture rates

– Denial rates for medical necessity of care
– Unspecified code use
– Provider engagement metrics including query response rates, query agreement rates, and
problem list updates
Ü Explain how physician documentation impacts publicly reported data (e.g., Hospital
Compare, Merit-based Incentive Payment System).
Ü Demonstrate a baseline of inpatient CDI knowledge, including basic differences between
inpatient and outpatient coding guidelines

5. Quality, regulatory, and health initiatives

Ü Demonstrate knowledge of the concepts of population health, including areas of CDI
collaboration with utilization review and care coordination
Ü Define the operations of the Medicare Shared Savings Program (MSSP)
– Describe Accountable Care Organizations (ACOs) and next generation ACO models
Ü Describe the basic functions of the Medicare Access and CHIP Reauthorization Act
(MACRA), including knowledge of:
– Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs)
– Quality reporting including the CMS Quality Payment Program and its measures
– Explain how RAFs impact quality scores and cost-efficiency metrics
– Demonstrate an understanding of CDI impact on documentation and code assignment as it
relates to quality reporting
Ü Explain the role of Medicare Contractors, including Medicare Administrative Contractors
(MACs) and Comprehensive Error Rate Testing (CERT) contractors
Ü Demonstrate a grounding in regulatory and association/best practice compliance documents
and initiatives
– Demonstrate how to develop a compliant query to the provider, as defined by Queries in
Outpatient CDI: Developing a Compliant, Effective Process
– Demonstrate what constitutes a leading query to the provider, as defined by Queries in
Outpatient CDI: Developing a Compliant, Effective Process
– Demonstrate an understanding of acceptable provider query formats (i.e., open ended,
multiple choice, and yes/no) and their proper application

© 2020 HCPro, a Simplify Compliance brand | 28

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

– Describe situations in which queries are not appropriate (i.e., diagnosis was not evaluated/
treated/monitored, etc.) and proper management of diagnoses that lack clinical support,
including process of clinical validation
– Define the goals and objectives of the Medicare Risk Adjustment Data Validation
(RADV) Program
– Identify compliance concerns regarding maintenance of the problem list
– Identify areas of potential noncompliance as identified by the Office of Inspector General
(OIG) in its Work Plan
– Maintain confidentiality of the medical record and other information relevant to the practice
of CDI, including core tenets of HIPAA

CCDS-O sample exam questions

Sample exam questions will be updated when vetted and approved by the Exam Committee.

On the day of your examination

On the day of your examination appointment, report to the Assessment Center no later than your
scheduled time. Once you enter the building, look for the signs indicating PSI Assessment Center
Check-In. A candidate who arrives more than 15 minutes after the scheduled examination time will
not be admitted.

To gain admission to the assessment center, you must present two forms of identification. The
primary form must be government issued, current and include your name, signature and photograph.
No form of temporary identification will be accepted. You will also be required to sign a roster for
verification of identity.

Examples of valid primary forms of identification are: driver’s license with photograph; state identification
card with photograph; passport; military identification card with photograph. The secondary form of
identification must display your name and signature for signature verification (e.g., credit card with
signature, social security card with signature, employment/ student ID card with signature).

If your name on your registration is different than it appears on your identification, you must bring
proof of your name change (e.g., marriage license, divorce decree or court order).

Candidates must have proper identification to gain admission to the Assessment Center. Failure to
provide appropriate identification at the time of the examination is considered a missed appointment.
There will be no refund of examination fees.

© 2020 HCPro, a Simplify Compliance brand | 29

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

After your identification has been confirmed, you will be directed to a testing carrel. You will be
prompted on-screen to enter your Social Security number. Your photograph will be taken and it will
remain on-screen throughout your examination session. This photograph will also print on your score
report.

Security
PSI administration and security standards are designed to ensure all candidates are provided the same
opportunity to demonstrate their abilities. The Assessment Center is continuously monitored by
audio and video surveillance equipment for security purposes. The following security procedures
apply during the examination:
Ü Examinations are proprietary. No cameras, notes, tape recorders, pagers or cellular/ smart
phones are allowed in the testing room. Possession of a cellular/smart phone or other
electronic devices is strictly prohibited and will result in dismissal from the examination.
Ü No calculators are allowed, nor is one required for the examination.
Ü No guests, visitors or family members are allowed in the testing room or reception areas.
Ü Candidates may be subjected to a metal detection scan upon entering the examination
room.

Personal Belongings
No personal items, valuables or weapons should be brought to the Assessment Center. Only wallets
and keys are permitted. Large coats and jackets must be left outside the testing room. You will be
provided a soft locker to store your wallet and/or keys with you in the testing room. The proctor will
lock the soft locker prior to you entering the testing room.

You will not have access to these items until after the examination is completed.

Watches, hats, wallets and keys are not allowed in the testing room except securely locked in the soft
locker.

Once you have placed your personal belongings into the soft locker, you will be asked to pull out your
pockets to ensure they are empty. If you bring personal items that will not fit in the soft locker, you
will not be able to test. The site will not store or be responsible for your personal belongings.

If any personal items are observed or heard (such as cellular/smart phones, alarms) in the testing
room after the examination is started, you will be dismissed and the administration will be forfeited.

© 2020 HCPro, a Simplify Compliance brand | 30

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Examination Restrictions
Pencils will be provided during check-in. You will be provided with one piece of scratch paper at a
time to use during the examination, unless noted on the sign-in roster for a particular candidate. You
must return the scratch paper to the proctor at the completion of testing or you will not receive your
score report.

No documents or notes of any kind may be removed from the Assessment Center.

No questions concerning the content of the examination may be asked during the examination.

Eating, drinking or smoking is not permitted in the Assessment Center.

You may take a break whenever you wish, but you will not be allowed additional time to make up for
time lost during breaks.

Misconduct
If you engage in any of the following conduct during the examination you may be dismissed, your scores
will not be reported and examination fees will not be refunded. Examples of misconduct include:
Ü Creating a disturbance, are abusive or otherwise uncooperative;
Ü Displaying and/or using electronic communications devices such as pagers, cellular/smart phones;
Ü Talking or participating in conversation with other examination candidates;
Ü Giving or receiving help or are suspected of doing so;
Ü Leaving the Assessment Center during the administration;
Ü Attempting to record examination questions or make notes;
Ü Taking the examination for someone else;
Ü Being observed with personal belongings, unauthorized notes, books or other aids.

Practice examination
Prior to attempting the timed examination, you will be given the opportunity to practice taking an
examination on the computer. The time you use for this practice examination is not counted as part
of your examination time. When you are comfortable with the computer testing process, you may
quit the practice session and begin the timed examination.

© 2020 HCPro, a Simplify Compliance brand | 31

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Timed examination
Following the practice examination, you will begin the timed examination. Before beginning, instruc-
tions for taking the examination are provided on-screen. The examination contains 140 questions.
Three hours are allotted to complete the examination.

The computer monitors the time you spend on the examination. The examination will terminate if
you exceed the time limit. You may click on the “Time” button in the lower right portion of the
screen to monitor your time. A digital clock indicates the time remaining for you to complete the
examination. The time feature may also be turned off during the examination.

Only one examination question is presented at a time. The question number appears in the lower
right portion of the screen. The entire examination question appears onscreen (i.e., stem and four
options labeled: A, B, C, and D). Indicate your choice by either entering the letter of the option you
think is correct (A, B, C, or D) or clicking on the option using the mouse. To change your answer,
enter a different option by pressing the A, B, C, or D key or clicking on the option using the mouse.
You may change your answer as many times as you wish during the examination time limit.

To move to the next question, click on the forward arrow (>) in the lower right portion of the
screen. This action will move you forward through the examination question by question.

If you wish to review any questions, click the backward arrow (<) or use the left arrow key to move
backward through the examination.

A question may be left unanswered for return later in the examination session. Questions may also
be bookmarked for later review by clicking in the blank square to the right of the Time button. Click
on the hand icon to advance to the next unanswered or bookmarked question on the examination.
When the examination is completed, the number of questions answered is reported.

If there is time remaining and you have unanswered questions, return to the examination and answer
those questions. Be sure to answer each question before ending the examination. There is no penalty
for guessing.

Online comments may be entered for any question by clicking on the button displaying an exclamation
point (!) to the left of the Time button. This opens a dialog box where comments may be entered.
Comments will be reviewed, but individual responses will not be provided.

© 2020 HCPro, a Simplify Compliance brand | 32

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Following the examination

After completing the examination, candidates are asked to complete a short evaluation of their exam-
ination experience. Candidates will receive their score report from the examination proctor. Scores
are reported in written form only, in person or by U.S. mail. Scores are not reported over the
telephone, by electronic mail, or by facsimile.

Your score report will indicate “pass” or “fail.” Additional detail is provided in the form of raw scores
by major content category. A raw score is the number of questions you answered correctly. Your
pass/fail status is determined by your raw score.

The methodology used to set the minimum passing score is the Angoff method, in which expert
judges estimate the passing probability of each examination question. These ratings are averaged to
determine the minimum passing score (i.e., the number of correctly answered questions required to
pass the examination).

If you pass the examination

If you pass the examination, you may use the designation CCDS immediately. Your certification is
valid for two years from the date of your exam. You will receive a certificate and lapel pin by US Mail
by the end of the month following the examination month.

Your employer, manager or supervisor should accept the score report as temporary proof that you
passed the exam until your certificate arrives by US Mail.

If you do not pass the examination

If you do not pass the examination, you may schedule a reexamination appointment by submitting the
Re-Exam application found on the ACDIS website. ACDIS will discount the exam fee to $125 for the
first retake only. Subsequent attempts to pass the exam will be at full price ($355, or $255 for ACDIS
members). There is a waiting period of ninety (90) days between examination attempts.

Appeals
Because the performance of each question on the examination that is included in the final score has
been pretested, there are no appeal procedures to challenge individual examination questions,
answers, or a failing score. The Certification Programs will always apply the same passing score (“cut
score”) and the same answer key to all candidates taking the same form of the exam.

Appeals may be made on the following grounds:

Ü Candidate eligibility
Ü Revocation of credential

© 2020 HCPro, a Simplify Compliance brand | 33

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

Ü Inappropriate examination administration procedures or environmental testing conditions

severe enough to cause a major disruption of the examination process

All appeals must be submitted in writing to:

ACDIS
Attention Certified Clinical Documentation Specialist Program
100 Winners Circle Suite 300
Brentwood, TN 37027
Or email: [email protected]

The candidate must explain in detail the nature of the request and the specific facts and circumstances
supporting the request, including reasons why the action or decision should be changed or modified.
The candidate must also provide accurate copies of all supporting documents.

Eligibility and revocation appeals must be received within thirty (30) days of the initial action. Appeals
for alleged inappropriate administration procedures or severe adverse environmental testing conditions
must be received within sixty (60) days of the release of examination results.

The Certification Programs will respond within thirty (30) days of receipt of the appeal. If this decision is
adverse, the candidate may file a second-level appeal within thirty (30) days.

A three-member panel of the appropriate Certification Board will review the initial decision and
respond with a final decision within forty-five (45) days of receipt.

Scores cancelled by ACDIS or PSI

ACDIS is responsible for the integrity of the scores it reports. On occasion, occurrences such as com-
puter malfunction or misconduct by a candidate may cause a score to be suspect.

ACDIS is committed to rectifying such discrepancies as expeditiously as possible. ACDIS may void
examination results if, upon investigation, violation of its regulations is discovered.

Copyrighted examination questions

All examination questions are the copyrighted property of ACDIS. It is forbidden under federal
copyright law to copy, reproduce, record, distribute, or display examination questions by any means,
in whole or in part. Doing so may subject you to severe civil and criminal penalties.

Confidentiality
Information about candidates’ examination results are considered confidential; however, ACDIS
reserves the right to use information supplied by or on behalf of a candidate in the conduct of

© 2020 HCPro, a Simplify Compliance brand | 34

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

research. Studies and reports concerning candidates will contain no information identifiable with any
candidate, unless authorized by the candidate.

ACDIS recognizes the achievement of all individuals who successfully complete the Certification
examinations on the ACDIS website or in CDI Journal. Applicants may decline this option on the
application form.

Duplicate score report

Candidates may purchase additional copies of their score reports at a cost of $25 per copy. Requests
must be submitted to PSI, in writing, within 12 months of the examination. The request must include
the candidate’s name, mailing address, telephone number, date of examination, and examination
taken. Submit this information with the required fee payable to PSI. Duplicate score reports will be
mailed within approximately five business days after receipt of the request and fee.

Recertification
The recertification process for the CCDS and CCDS-O ensures that clinical documentation improve-
ment professionals stay abreast of changing government and private-payer regulations, documenta-
tion and coding requirements, and important developments in the field of CDI.

Individuals who hold either credential must apply for recertification every two years from the date on
which they passed the exam. Certification holders must submit evidence of 30 Continuing Education
Units (CEUs) relevant to the field of CDI by using the Credentialing Center website found on the
ACDIS website and at https://ccds.simplifycertifications.com/login. Re-taking the CCDS/CCDS-O
examination is not necessary unless the certification holder fails to recertify within one year of the
recertification due date.

Individuals who hold both credentials simultaneously must submit a combined total of 40 CEUs
relevant to the field of CDI. ACDIS will establish a single recertification date, which shall be every
two years from the date on which they passed their second exam. For example, if a candidate
successfully passed the CCDS Exam on Jan. 1, 2018, then passed the CCDS-O exam on Oct. 1, 2018,
his or her recertification due date for both credentials by which he or she must submit 40 CEUs
would be Oct. 1, 2020.

Please review the document CEU Qualifying Activities for examples of acceptable CE activities. ACDIS
sends email reminders as an individual’s recertification due date approaches but it not responsible for
late recertification because of undelivered or ignored email.

© 2020 HCPro, a Simplify Compliance brand | 35

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

It is the individual’s responsibility to update address and email changes with the ACDIS office. Send
updates or changes to Customer Care, [email protected].

Individuals who fail to recertify in a timely manner may incur a late fee or have their certification
revoked. ACDIS does not issue a new certificate for recertification but sends a letter and wallet card.
Replacement certificates can be purchased for $25.

Although ACDIS strongly recommends submitting the required CEUs by the two-year recertification
date, certification holders are extended a 45-day grace period to submit their CEUs. Failure to
submit CEUs within this 45-day grace period will result in suspension of the credential. A former
credential holder may recertify by reapplying for and successfully passing the appropriate exam.

A percentage of participants will be audited to ensure that they have met the CEU requirements.
Individuals who hold the CCDS or CCDS-O should keep a record of participation in all of their CEU
qualifying activities in the event of an audit.

Certification maintenance fees

ACDIS members pay a certification maintenance fee of $100 when submitting their CCDS or CCDS-O
Recertification Application The fee for non-ACDIS members is $200.

ACDIS members who hold both the CCDS and CCDS-O pay a certification maintenance fee of $175
when submitting their joint Recertification Application. The fee for non-ACDIS members is $275.

Failure to renew
A certificant who fails to renew his or her certification is no longer considered certified and may not
use the credential in professional communications, such as on letterhead, stationery and business
cards, in directory listings, or in signature.

Disciplinary policy
The CCDS and CCDS-O Certification Committees are independent and autonomous bodies within
ACDIS that has been established to oversee and manage the Certified Clinical Documentation
Specialist certification programs. In order to maintain and enhance the credibility of the CCDS
certification program the Certification Committees have adopted the following administrative
procedures to allow individuals to bring conduct-related complaints to the attention of ACDIS.

The Certification Committees shall undertake sanctions against applicants, candidates, or individuals
relating to failure to meet requirements for initial certification or recertification, or misrepresentation/
misuse of the certification. The certification programs are a voluntary process, not required by law

© 2020 HCPro, a Simplify Compliance brand | 36

 Certified Clinical Documentation Specialist
CANDIDATE HANDBOOK

for employment in the field. Monitoring and evaluating actual job performance is beyond the scope of
the Certification Boards or ACDIS.

Applications may be refused, candidates may be barred from future examinations, or candidates or
individuals already certified may be sanctioned, including revocation of their certification designation,
for the following reasons:
Ü Attesting to false information on the examination application, recertification documents, or
during random audit procedures of both forms
Ü Giving or receiving information to or from another candidate during the examination
Ü Removing or attempting to remove examination materials or information from the
testing site
Ü Possessing or distributing unauthorized official testing or examination materials
Ü Representing oneself falsely as a CCDS or CCDS-O

The Certification Boards note that the ACDIS Code of Ethics applies to all ACDIS members, as well
as any professionals holding the CCDS and CCDS-O who are not ACDIS members.

Contact us
If you have questions regarding the CCDS or CCDS-O exam or their requirements, please email
Customer Care at [email protected]

You may also write to:

Simplify Compliance
100 Winners Circle, Suite 300
Brentwood, TN 37027
Tel: 877-240-6586
Web site: www.acdis.org

© 2020 HCPro, a Simplify Compliance brand | 37