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Note from the CCDS Coordinator: Happy birthday, ACDIS!

Penny

CCDS Coordinator Penny Richards

by Penny Richards

ACDIS and I are both celebrating our birthday this week. ACDIS is turning 10. I turned 10 a long time ago.

In 2007 (the year of ACDIS’ “birth”):

  • Apple launched the iPhone
  • Bob Barker appeared for the last time as host of “The Price is Right”
  • “Harry Potter and Order of the Phoenix” debuted in theaters
  • Helen Mirren won the Oscar for best actress for “The Queen”
  • The Boston Red Sox swept the Colorado Rockies to take the World Series

In the year of my birth: [more]

Note from the CCDS Coordinator: Is it time to recertify your CCDS credential?

ACDIS 522

CCDS Coordinator Penny Richards

by Penny Richards

In the next couple months, hundreds of CCDS holders will need to recertify their credential. Even those who’ve gone through the process may need a quick refresher. So, without further ado, here are some tips and hints to help you have a smooth recertification process.

You may recertify up to 60 days before your due date. Not sure when it is due? Look at the date on your certificate (the one you have framed and hanging on the wall, of course). Your recert is due every two years from the date you passed the exam. You can also email me (prichards@acdis.org) and I’ll check your due date in the CCDS database.

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Website Tips: How to find out whether your activity qualifies for CCDS CEUs

A few weeks back, CDI Strategies included a column about earning CCDS continuing education credits (CEUs) through your ACDIS membership. But, how can you tell what activity outside of ACDIS qualifies for CEUs?

Outside of ACDIS and HCPro activities covered in last week’s column, here are a few ways to earn CEUs:

  • Complete college courses relevant to healthcare/healthcare management, CDI, or clinical coursework for credit or degrees
  • Present CDI-related topics at seminars/speaking engagements outside of regular work activities (please note that the program must be accredited through the appropriate professional organizations, include a timed agenda, and documentation of program objectives)
  • Submit activities from other organizations that provide education or training in CDI, ICD-10, clinical, coding, documentation improvement activities, or diagnosis/pathophysiology

For any single event from other agencies or organizations, ACDIS will accept up to 10 of the CEUs offered. If the program and certificate of completion specifying that the CEUs are specifically for the CCDS, then ACDIS will accept all the CEUs, even if there are more than 10 offered.

Editor’s note: To see a complete list of places to receive CEUs, click here. To read more about certification, click here.

 

Summer Reading: Tips for preparing for the CCDS exam

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

Once you have met the two-year minimum work experience requirement required to sit for the Certified Clinical Documentation Specialist (CCDS) credential exam, it’s time to study. Start by reviewing CCDS Exam Candidates Handbook for information on applying to sit for the exam as well as the process for taking the test. The following are a few additional tips that many successful candidates have used to earn their certification:

  • Discuss with peers and supervisors
  • Join a study group
  • Visit the CCDS discussion board on the ACDIS Forum
  • Start studying early like a few months prior to sitting for the exam
  • Review a new content area each week
  • Spend extra time studying areas where you feel less confident
  • When reviewing practice questions multiple times, make sure you understand the concept and don’t just memorize an answer
  • Take a day or two to prepare your mind and body for the exam
  • Get a good night’s sleep and eat a good meal before taking the exam
  • Leave plenty of time to arrive for the exam

Once you are set to begin the exam, take a deep breath, exhale, and let your knowledge and experience guide you through successful completion of the certification.

Editor’s note: This article is an excerpt from the “CCDS Exam Study Guide,” by Fran Jurcak, MSN, RN, CCDS. To read more about certification, visit the ACDIS website, here.

 

Book Excerpt: CCDS exam format

Jurcak

Fran Jurcak, MSN, RN, CCDS

By Fran Jurcak, MSN, RN, CCDS

The CDI specialist role is complex and multidisciplinary, suitable for clinically knowledgeable professionals who are proficient in analyzing and interpreting medical record documentation and capable of tracking and trending their CDI program goals and objectives. These professionals possess knowledge of healthcare and coding regulations, anatomy, physiology, pharmacology, and pathophysiology. Furthermore, such professionals possess the valuable ability to engage physicians in dialogue and educational efforts regarding how appropriate clinical documentation benefits patient outcomes and the overall well-being of the healthcare system.

Therefore, the CCDS exam content stems from:

  • Analysis of the activities of clinical documentation specialists in a wide range of settings, hospital sizes, and circumstances
  • Input from ACDIS member surveys
  • Input and research of the CCDS advisory board comprised of experienced clinical documentation specialists

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Note from CCDS Coordinator: Do you really need the CCDS certification?

CCDS certification

I received an interesting question recently from someone contemplating Certified Clinical Documentation Specialist (CCDS) certification. She asked:

“I am wondering whether obtaining the certification gives the CCDS holders any special privileges? Are they able to perform duties that they otherwise would not be able to if they did not hold the certification (not by knowledge, but by law)?”

In my five-plus years with ACDIS no one has ever asked this question. Obtaining the CCDS credential does not give the holder any additional rights, privileges, or responsibilities. It does not legally empower the holder to perform any duties.

What the CCDS credential does, however, is recognize individuals who have an advanced level of CDI knowledge and who have the proven ability to work as clinical documentation specialists. Candidates for the CCDS designation are required to have at least two years of experience in the profession.

The CCDS demonstrates an accomplishment that captures both experience and knowledge in the field, and many facilities suggest or require their CDI staff hold the CCDS or earn it following the two-year minimum requirement to sit for the exam, after hire. Facilities often hire individuals with nursing (clinical) or coding experience for the clinical documentation team and train them to become proficient. It is the decision of the individual facility to determine who to employ as a CDI specialist and what responsibilities are given to individuals who perform the CDI role, which may differ depending on whether or not they hold the certification.

What I didn’t tell the writer is that, for a lot of people, CCDS certification is a matter of pride. In the fall of 2016, ACDIS conducted a survey of CCDS holders and asked them what they see as the value of their credential. Their responses included:

  • The credential differentiates me as a leader
  • I am set apart as the CDI who went the extra mile to prepare for and achieve the certification for my very specialized profession
  • I am the go-to-person for others to come to with questions for assistance
  • The credential demonstrates that I put forth the effort to be knowledgeable about the work I perform
  • Professional certification is about promoting the highest standards in our industry
  • Personal satisfaction
  • It shows I take my job seriously and intend to stay on top of the knowledge I need to do the job well
  • It shows I have the experience of clinical chart review for appropriate diagnoses and the clarification/query process to physicians
  • The credential sets me apart—I have skills and knowledge
  • It’s proof that I value this job, want to continue to do it, and want to improve myself; I feel it’s a definite plus and shows that I take pride in what I do.
  • It adds much credibility with the physicians in my institution—I think I am perceived as being more professional and more knowledgeable in my role

From the same survey, several managers told us:

  • Certified individuals are viewed as more knowledgeable about coding guidelines and best practices. They are more committed to their work, better trained, and have better understanding of the role and what is required to do the job well. And because of recertification requirements, they stay current with changes in the industry.
  • Certification holders often serve as team leads, help with new staff orientation, and staff education.
  • It communicates a commitment to their craft. Requirements are such that they have to stay current with on-going changes that are occurring. It helps when interacting with their “customers,” as they really are trained and understand what they are doing.
  • Identifies that you have attained increased knowledge related to your daily practice.

What will drive you to seek CCDS certification? Whether personal pride, or a suggestion or requirement from your employer, we are here to encourage your efforts and cheer your accomplishment.

Visit the ACDIS website and download the Exam Candidate’s Handbook for more information about certification.

Editor’s note: Penny Richards is the CCDS Coordinator for ACDIS. If you have any questions regarding the CCDS credential or exam process, contact her at prichards@hcpro.com.

Note from the Instructor: Take personal responsibility for professional advancement

Prescott_Laurie_web

Laurie L. Prescott, RN, MSN, CCDS, CDIP

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 lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

A Note from the CCDS Coordinator: What CEUs can I submit for my CCDS recertification?

CCDSpinACDIS will accept as many CDI-related CEUs from other organizations (such as AHIMA and JATA) as you wish to submit with this exception: For any event that awards more than 10 CEUs, we will accept 10.

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:

Item 6:
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.

Item 7:
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 Note from the CCDS Coordinator: Congratulations to our 3,500th CCDS holder!

The 3,500th CCDS holder Jamie Brown and her two children—daughter, Kaitlyn, age nine, and son Cody, age seven.

The 3,500th CCDS holder Jamie Brown and her two children—daughter, Kaitlyn, age nine, and son Cody, age seven.

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

A Note from the CCDS Coordinator: Exam prep tips from our education director

CCDS Exam Study Guide

CCDS Exam Study Guide

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:

  1. Use the CCDS Exam Study Guide, which comes with an online practice test.
  2. 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.
  3. Read the 2016 ACDIS/AHIMA Query Practice Brief to help you understand compliant query practices.
  4. 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.
  5. 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.
  6. Understand sequencing rules.
  7. A CDI Boot Camp would be helpful if you have the time and resources.
  8. Think about how you perform the role of CDI, how you review a record, and prioritize patient care.
  9. 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.
  10. 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.
  11. 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.