By Laurie L. Prescott, RN, MSN, CCDS, CDIP
It has been 10 years since I turned the focus of my career to the practice of CDI. About a year ago, I found myself calling it a “profession.” I have been a proud member of the nursing profession for more than 30 years. In both my personal and professional life, I tried my best to represent my profession and demonstrate that nurses are highly competent, knowledgeable leaders in providing healthcare to patients. Nurses have been granted the privilege of witnessing and assisting others in their most intimate moments of life.
I never wanted to minimize the role of a nurse, nor misrepresent it in any way. I feel very much the same about the profession of CDI. We serve a very important role in our organizations in that we work to ensure our patient’s stories are told accurately and completely.
The profession of CDI encompasses a number of different titles, credentials and professions besides nursing, to include medicine and coding. And I am sure no matter how a person landed in CDI they too are as proud of their specific profession that started them off as I am of my nursing background. And I am sure, too, that most are also proud of the fact they are now a member of the CDI profession. (Read the recently released “CDI: More than a credential,” position paper from the ACDIS Advisory Board.)
Google the word profession and the definitions returned are all similar. Most state that a profession describes an occupation requiring specialized education, knowledge, training, and ethics. Members of a profession are expected to meet and maintain a common set of standards. Skills and knowledge are obtained through the process of lifelong learning and continuing professional development. Indeed, the ACDIS Code of Ethics reinforces that commitment to lifelong learning.
I was always taught that a profession must have a developed body of knowledge. The ACDIS Code of Ethics addresses this as well with the statement, “Clinical Documentation Improvement Professionals must advance their specialty knowledge and practice through continuing education, research, publications, and presentations.” It is up to each and every one of us to grow our body of knowledge.
So my question to you is—what have you done lately to represent your profession?
We all need to be leaders. That does not mean you have to speak at the national conference, or write articles and books, but it could mean becoming a leader within your own hospital organization or helping with your local ACDIS chapter.
When I was working daily in the CDI role, I spread the word of CDI in an activity I called the “CDI Road Show.” I took the road show to anyone, any department that invited me. (And even to some that did not extend an invitation!) I wanted everyone to know what we did because their support of those efforts could help foster our success.
I wanted to represent my profession well; meaning I tried to demonstrate competence, knowledge, and commitment to ethical practice in every activity and exchange performed. This commitment was as much for myself as it was for all the CDI specialists I worked with. If I presented as well prepared and knowledgeable to a provider, the next time that provider spoke to another team member he or she would understand the skills our CDI team brings to the game. If I could speak concisely to administration and communicate both the value of CDI and the needed resources, the administrative team would see all CDI staff as professionals, too.
And so, I encourage you to step up. Volunteer to serve on a committee. Start a “road show” of your own. Mentor a new CDI. Learn something new today.
Most importantly, walk strong and tall and demonstrate to the world the CDI professional that you are.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, is a CDI Education Specialist at HCPro in Danvers, Massachusetts. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.
For example, if you attend an AHIMA training and it awards (for example)15 CEUS, we will accept 10 for your recertification.
If you attend an AHIMA webinar or similar training that awards you one or two CEUs, we will accept as many of those events as you wish to submit. We’ll accept the entire 30 you need to recertify.
The key is that no single event can award more than 10.
The same applies to CEUs you earn from ANCC, AAPC, CME, and other agencies that provide CDI-related training. We consider CDI-related training to be the exact kinds of training you mentioned in your initial email: CDI, inpatient coding, technology, DRG, reimbursement, plus anatomy and physiology, ICD-10 disease process.
The document on our website explains how we count CEUS from other agencies:
Submit up to 10 CEUs for other single activities that provide CDI training and education, ICD‐10, clinical (disease or diagnosis), coding, documentation improvement activities, or diagnosis/pathophysiology education from other organizations, such as AHIMA, AAPC and ANCC, and CME credits.
Submit CEUs at a rate of 1‐for‐1 for individual training and education activities that are CDI training and education, ICD‐10, clinical (disease or diagnosis), coding, documentation improvement activities, or diagnosis/pathophysiology education from other organizations, such as AHIMA, AAPC and ANCC, and CME credits.
We routinely accept training from companies such as 3M and Precyse as long as it is CDI-related training, to a maximum of 10 for any single training event. Some companies, such as 3M, Panacea, and Reimbursement Review Associates, have purchased ACDIS CEUs for their large programs, and we accept all of these CEUs. You’ll know if you can submit them all because the certificate will clearly indicate that the program awarded a specific number of CCDS CEUs.
Click here to learn more about CCDS certification.
A couple of weeks ago, the 3,500th person to hold the CCDS certification passed the exam. We are delighted to introduce you to Jaime Brown, BSN, RN, CCDS, a CDI specialist at Ochsner Health System at Jefferson Parish, Louisiana. Please join us in congratulating her on this tremendous accomplishment!
Before becoming a nurse, Brown had a career as a commercial loan underwriter for a major financial institution before obtaining her bachelor of science in nursing. She worked in oncology for seven years and has been in CDI for three years.
“CDI has been an awesome professional opportunity,” says Brown. “I have had the opportunity to increase my clinical knowledge, learn the financial side of healthcare, and be a part of the formative years of this unique profession all while having the flexibility to be there for my children when they need me.”
Brown has two children—daughter, Kaitlyn, age nine, and son Cody, age seven. She enjoys her free time trying new restaurants and catching up with family and friends.
ACDIS: Why did you get into this line of work?
Brown: I was looking for a change and saw the job posting. It peaked my curiosity because it was the “business” side of nursing.
ACDIS: What has been your biggest challenge?
Brown: The biggest challenge for me is that there is usually not a straight answer to a question. Each admission is different and no two clinical scenarios are the same.
ACDIS: What has been your biggest reward?
Brown: The biggest reward has been seeing the financial and quality impact I can have through my chart reviews. It’s always nice to query for the only MCC on a record or clarify something with a provider so that their record is accurate. Although I am not at the bedside, I can still make a difference. I also feel like I have learned more from a clinical aspect in the last three years in CDI than I did in my seven years at the bedside.
ACDIS: How has the field changed since you began working in CDI?
Brown: When I started in CDI, we were still in ICD-9. Most people had not heard about CDI. We worked strictly with inpatient records. Today, we code in ICD-10. Other medical professionals have heard about our role and providers are looking to expand our role. My employer now has an additional program specifically for reviewing ambulatory records. (Click here to learn more about that program.) I can only imagine where CDI will be in another three years.
ACDIS: Can you mention a few of the “gold nuggets” of information you’ve received from colleagues on CDI Talk or through ACDIS?
Brown: One of our primary responsibilities as CDI professionals is to educate providers. When I started, I often wondered if we would ever educate them enough to the extent that we would be out of a job. I have learned rather quickly that CDI will always be in demand because the rules are so complex and there are always new providers to train. If you miss a query opportunity, it is a learning opportunity.
ACDIS: What piece of advice would you offer to a new CDI specialist?
Brown: There is a learning curve in this job like none other. Just when you think you understand the concepts, you will be faced with a situation that makes you question your new found understanding. Confidence and understanding come with time. Be patient.
ACDIS: If you could have any other job, what would it be?
Brown: I would love to be a personal financial advisor, managing everyday household finances. I love a spreadsheet and have serious organizational skills. I make a spreadsheet for just about everything, including vacations!
ACDIS: What was your first job (what you did while in high school)?
Brown: I was a store clerk at Afterthoughts Boutique in high school. I pierced ears and sold jewelry and hair accessories.
ACDIS: Can you tell us about a few of your favorite things:
- Vacation spots: Chicago and Florida beaches
- Hobby: Dining at new restaurants–there are always new places to try in New Orleans
- Non-alcoholic beverage: Diet Coke
- Foods: Boiled crawfish and steak
- Activity: Hanging out with my kids and friends
by Penny Richards
As the coordinator for the Certified Clinical Documentation Specialist (CCDS) exam program, lots of folks ask me for CCDS exam prep tips. But I’m not a CDI professional—I don’t even play one on television—so I asked our CDI Education Director and Boot Camp instructor, Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, for her expert advice.
“Some of getting ready for the exam is mental,” she told me. “If you’ve been working as a clinical documentation specialist for the minimum two years required [to sit for the exam], and you understand the role, you likely have the skills you need to pass.”
Prescott also provided me with a list of great tips that I thought I’d share with you:
- Use the CCDS Exam Study Guide, which comes with an online practice test.
- If you are an ACDIS member, take advantage of the great information on the website and the ACDIS Forum to talk to other members about their preparation and exam experiences.
- Read the 2016 ACDIS/AHIMA Query Practice Brief to help you understand compliant query practices.
- You must know how to use the DRG Expert. If you are encoder dependent and don’t know how to use the book, you’re going to have a difficult time. Find someone who can show you how to use the book, perhaps a member of your CDI or coding department. It’s not easily self-taught.
- Read the Official Guidelines for Coding and Reporting and be aware of the importance of the AHA’s Coding Clinic for ICD-10-CM/PCS. I am always amazed by the number of people working in CDI who have never picked up a coding book or read coding guidelines.
- Understand sequencing rules.
- A CDI Boot Camp would be helpful if you have the time and resources.
- Think about how you perform the role of CDI, how you review a record, and prioritize patient care.
- Metrics and analytics measure department success and some CDI specialists may not be familiar with this aspect of the program. Sit with your manager and ask him or her how to develop and interpret the data. Learn how to define and calculate the case mix index. Know what a query response rate is.
- Think about areas you may not have a lot of experience in, such as a specific clinical subject, procedures, etc., and study up on this area. Remember, this exam tests the overall function of CDI practice, meaning it may cover information not currently pertinent to your role due to the limitations of your facility.
- Finally, while it’s important to study and prepare, don’t try to do it all the night before. Eat a good dinner and get a solid night of sleep.
Thank you, Laurie, for providing these tips! For more information on CCDS certification, click here.
by Penny Richards
As always, feel free to drop me a note if you have questions.
Q: How far in advance can I renew my CCDS certification?
A: Please submit no more than 60 days prior to expire date. Your expiration date is every two years from the date you took the exam. That date is on your certificate and on the score sheet you received when you took the exam.
Q: What do you recommend as the best way to submit my recertification?
Q: I don’t see a way to do it online but do see a fax number.
A: There is no online application option offered.
Q: Do you recommend faxing the form, e-mailing it to you, or putting it in the mail?
A: Return it in whatever way you wish. Instructions are on the form.
Q: Is it ok to submit more than the required 30 or should I just stop once I reach 30 hours.
A: You only need to submit 30 hours. All CEUs must have been earned in the time you held the certification. Remaining CEUs cannot be used for a future recert. Note the restrictions outline on the form (not more than 10 CEUs for any single event other than certain HCPro-sponsored programs).
I just got an email from someone asking when his CCDS recertification is due. Unfortunately it expired 19 months ago, and when I told him, he was quite surprised.
“How can that be? I paid my ACDIS dues.”
ACDIS membership is not tied to CCDS certification. You don’t have to be an ACDIS member to hold the CCDS—and you don’t have to hold the CCDS to be an ACDIS member.
We encourage ACDIS membership for CCDS holders, if for no other reason than, with membership, they can earn 10 FREE continuing education credits each year toward the 30 they need to recertify every two years. That’s just one great benefit of membership.
Do you hold the CCDS certification? Do you know when it expires? Look on your CCDS certificate (it’s framed and hanging on the wall, right?) or look at the score sheet you received the day you passed the exam. Your CCDS recert is due two years from the date you took the exam.
There is a 45-day grace period to recertify without penalty and we will work with anyone with a recertification that is up to 12 months overdue. After a year, your CCDS is revoked and you must take the exam again in order to hold the CCDS.
Click here to email me if you need to know your CCDS recertification due date. Include your name, facility, home address and phone number. We’ll update the database as necessary. It is your responsibility to notify ACDIS of contact changes.
ACDIS is not responsible for expired certifications if we can’t reach you with email reminders. It is important to note that the HCPro Customer Service database is separate from the CCDS database, which is why we remind you to contact the ACDIS CCDS office with changes. We’ll share the changes with Customer Service.
You worked too hard to earn the CCDS. Don’t give it give it away on an oversight.
Tomorrow, Wednesday, August 19, from 1-2 p.m., ET, our own CCDS Coordinator Penny Richards, CPC-A, joins Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer and Fran Jurcak, MSN, RN, CCDS, for a free, 60-minute webinar exploring the most frequently asked questions regarding the Certified Clinical Documentation Specialist (CCDS) credential and examination process. During the call, the panel will discuss:
- How to apply
- How to prepare for the exam
- What resources are available for study
- Re-certification processes
In addition to the agenda, speakers will be answering questions live. To register, visit “CCDS FAQ: Everything You Need to Know About Taking the ACDIS CCDS Certification Exam.”
Quarterly Conference Call
ACDIS members can dial-in to a free topic-focused telephone conference call with leaders and Advisory Board members this Thursday, August 20, from 1-2 p.m., ET. This quarter’s agenda includes:
- Pulling past medical history forward from EHR for CDI purposes
- Ethics and ethical CDI practices
- The role of the physician advisor in CDI
- Your Q&As
We want your ideas and questions!
If you have a question to ask the ACDIS advisory board, or general suggestions for discussion on the upcoming call, please e-mail Associate Director Melissa Varnavas at email@example.com.
Conference calls are a great way to ask a question, air any and all CDI concerns, or gather input on a policy or procedure at your hospital. ACDIS members have access to this and all the Quarterly Conference Calls Archives on our website www.acdis.org. While we cannot guarantee your question or discussion point will be addressed on the call, we will try to work in as many as possible.
Please note that due to heavy call volume, we recommend that you dial in 10 minutes early. Dial-in instructions were set to ACDIS members via email this week. If you are an ACDIS member and did not recieve your instructions, call our customer service department by no later than 11 a.m. on the day of the live call at 877-240-6586 or email firstname.lastname@example.org
We look forward to talking with you then!
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone over the weekend: on Saturday, the 2,500th person to pass the exam took the test and received their certification. While we are thrilled with the success and growth of the CCDS credential, we know there are still hundreds of hopeful CDI specialists out there wondering, “How do I become certified?” We’ve been getting a lot of questions lately about eligibility for the CCDS certification and recertification and thought we’d offer some advice.
Certification eligibility requirements
Candidates who apply for the examination must cite their concurrent documentation specialist experience on their application. Applications may be audited to verify work history and educational background. Candidates must have at least two years of experience as a documentation specialist. Once a candidate has accumulated the time, it does not expire. All work experience must be met at the time the application is submitted.
Candidates must demonstrate that they meet one of the following requirements:
- An RHIA®, RHIT®, CCS®, CCS-P®, RN, MD or DO and two (2) years’ experience as a concurrent documentation specialist.
- An associate’s degree (or equivalent education) in an allied health field and three (3) years of experience as a concurrent documentation specialist. The education component must include completed coursework in medical terminology and anatomy and physiology.
- Formal education (accredited, college-level course work) in human anatomy and/or physiology, plus medical terminology, and disease processes, and a minimum three (3) years’ experience as a concurrent documentation specialist
Please note: [more]
We’re happy to hear that you’re interested in joining the CDI profession. You do not need to have the CCDS credential to become a CDI specialist. The CCDS represents a mark of distinction for those who have been working in the field for a number of years. In fact, you must be a working CDI specialists for at least two years before you can sit for the exam.
If you are interested in becoming a CDI specialist we recommend that you first learn as much as possible about the field. Review the materials on the ACDIS website (much of it is free) and take lots of notes. If you have a local chapter in your area, call or email the leadership and ask if you can attend a meeting. If you have a CDI program at your facility, ask the program staff if you can shadow them for a day to learn more about the work they do. If you do not have a CDI program at your facility, reach out to neighboring hospitals and see if their program would host you for a morning or an afternoon.