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Update on certification, including prerequisites

General requirements

  • Candidates applying for the examination will be required to list their documentation specialist experience. Applications may be audited to verify work history.
  • Once a candidate has accumulated the necessary hours these do not expire.
  • All work experience must be met by the application deadline.
  • At least one year of documentation specialist experience or equivalent is required for each eligibility requirement.

Allowable resources

Examination takers for the CCDS will be allowed to bring the following two books with them into the examination:

  • DRG Expert, published by Ingenix
  • Standard drug reference guide

Books will be checked for additional pages or loose notes inserted or attached inside. These are not allowed to be brought into the exam. Test-takers may write hand-written notes into the books but not to an excessive degree.

Thanks, and please ask your questions here, or e-mail me at


Clinical documentation specialists of Northeast Region hold first meeting at South Shore Hospital

acdis_groupLast Tuesday, Oct. 28, a group calling itself the Clinical Documentation Specialists of the Northeast Region held its first meeting at South Shore Hospital in Weymouth, MA. Gail Marini, Trish Nash, and Amy Trout of South Shore Hospital organized the meeting, and since ACDIS is located only an hour or so down the street (in Marblehead, MA), the three ladies were kind enough to invite myself to the meeting to speak about ACDIS and our upcoming certification exam.

For a first-ever meeting the turnout was great with some 33 clinical documentation specialists and a few HIM professionals gathered together in a conference room. [more]

ACDIS clinical documentation certification underway

Earlier this week (October 20 and 21), four members of the ACDIS-sponsored clincial documentation certification advisory board took a trip out to our home base here in Marblehead, Massachusetts, to begin the next and most important phase of our upcoming certification–writing test questions.

Under the guidance of a recognized national certification administration firm, Deborah Biskner, MBA, RHIA, CCS, a clinical documentation specialist from Port Huron Hospital in Michigan, Jill Brocker, RN, MSN, CCS, director of quality services for Indiana Heart Institute in Indianapolis, Mary Beth Brown, RN, BSN, manager of clinical documentation improvement/utilization review for Moses Cone Health System in Greensboro, North Carolina, and Mary Phelps, RHIA, CCS, CTR, CIC, senior associate for PricewaterhouseCoopers LLP in Charlotte, North Carolina, flew into Logan Airport to get started.


Continuing CDI Education: Where does it come from?

How many of you have read the Official Coding Guidelines for 2008? Anyone? Anyone??

Well, if you haven’t yet, why haven’t you? As CDI professionals I believe that it is our responsibility to make every effort to stay abreast of coding regulations and updates and how they affect our process.

The 3rd Quarter Coding Clinic updates were available earlier this month. It should be standard practice to read the updates and see if there’s something new you need to know.

ACDIS on the home front

If you’ve been a reader or a poster on CDI Talk you may have noticed that there have been several questions and replies about local ACDIS chapters or networking groups. No matter what area of the country you’re in, it’s clear that everyone is looking to connect with their “soul mates” in CDI.

If you’re an individual or a hospital looking to meet with your peers I can tell you how our group, Northern Illinois CDI Network, came into being. Maybe it’ll give you some ideas on how to get your own group going. [more]

Pressure Ulcer Coding and Staging

Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I can hardly believe what I’m seeing.

I’ve seen wound care flow sheets where vascular or diabetic ulcers are incorrectly documented with a stage (which should only be assigned to pressure ulcers) and I’ve seen pressure ulcers go from stage I to stage III or from stage III to stage I between one shift and the next. [more]

POA: Episode II

episode_2_jedi_knight3Preface to the following: You won’t find a more staunch advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and processes that support those aims.

However, we all also know that when it comes to implementing new initiatives it’s the bottom line that makes the decisions. That being said…

Once upon a time in a galaxy far, far away there existed an entity known as CMS, sometimes called the Empire. The Empire controlled everything in its purvue, including hospital reimbursement.

Last year the Empire passed a new law called “Present on Admission (POA)”. All the citizens who reported to the Empire lived in fear of this new law but the first year passed without any significant battles.

Episode 2:
I suspected (as I’m sure you all did) that once the Empire announced that it would exclude payment for hospital-acquired conditions, it was only a matter of time before the commercial carriers followed suit. Guess what? It happened.


After the consultants leave…what now?

Hey, you CDS with new programs out there! How’s it going? Are you sailing along on the smooth seas of phenomenal MCC capture rates or are you stalled in the doldrums? Are you asking yourself the following question: “What do I do now that the consultants are gone?

Been there. Done that …twice, in fact! Are you finding that the people at your hospital who decided that a CDI program was a good idea are now saying things like “the CMI doesn’t seem much different” or “where’s the money they promised us”?

Don’t feel bad. You didn’t do anything wrong. You’re just feeling the pangs of aftermath: the training and support is over and now you’re alone and administration doesn’t even know what you do, exactly.

First, who do you report to? Someone who actually knows from a hole in the ground, or someone who wouldn’t know an MCC if it bit them? This isn’t a silly question. If the person making the decisions doesn’t know what you’re REALLY there for, it’s going to be hard to succeed and grow your program. So, invite this person to come to your team meetings and be sure to share your successes and tell him/her how much more you can do with their active support. [more]

How to make a CDIS

While those of us at ACDIS are already working as CDIS there are nurses and coders out there who e-mail me and ask how to become a CDIS so I thought I’d write about what I look for when I’m hiring someone.  FYI, folks, opinions ahead. [more]

AHIMA Takes Second Look at Revised Physician Query Practice Brief

handsBrian Murphy, director of ACDIS, asked me to say something about AHIMA’s decision to revise the Physician Query Practice Brief and provide some commentary on the first draft.  While I’m unable to provide the complete text here I’ll try and paraphrase the sections that, in my opinion, still need some clarification and I’ll give some examples of the sections that I agree with.

The revised brief is presented in two sections:

  1. the first addresses current legal, regulatory and ethical issues, documentation, the query process
  2. the second part provides direction concerning compliance; specifically, auditing and monitoring and reporting and performance metrics

What the brief does not do is answer the all-time burning question “what constitutes a leading query?” or acknowledge that there is a difference between a nurse asking a physician a question (clinician-to-clinician) and a coder querying the physician.  I feel that the “guidance” provided in the first draft does anything but guide.