CCDS Exam Study Guide, Fourth Edition

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CCDS Exam Study Guide, Fourth Edition

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CCDS Exam Study Guide, Fourth Edition

Fran Jurcak, RN, MSN, CCDS

The first two years of a Clinical Documentation Improvement (CDI) specialist’s career often feels like a whirlwind of learning. Many in the field call it the steepest learning curve of their professional lives. After their two-year anniversary, committed individuals can show their professional dedication by sitting for the Certified Clinical Documentation Specialist (CCDS) exam.

The CCDS Exam Study Guide, Fourth Edition, helps those ready to sit for the test ensure they’re prepared to excel.

The latest edition aligns the testing content domains in a chronological manner with how new CDI professionals obtain core skill sets. The Study Guide provides targeted information regarding test objectives prepared by the CCDS Certification Committee, letting candidates focus their time on areas of CDI practice with which they are least familiar.

This new version includes updates related to changes in Official Guidelines for Coding and Reporting, Coding Clinic ICD-10-CM/PCS recommendations, new query practice guidance from ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice,” and information on emerging CDI activities related to clinical validation and record reviews for quality-of-care concerns.

Spiral bound to make studying with colleagues easier, it also comes with an updated 100 question practice exam complete with remediation, so candidates can quickly understand why an answer is correct.

The CCDS Exam Study Guide, Fourth Edition will:

  • Help candidates determine whether they are ready to take the CCDS exam
  • Give qualified candidates the confidence they need to succeed
  • Provide sample questions for self-assessment

The CCDS Exam Study Guide reviews:

  • The inpatient prospective payment system (IPPS)
  • ICD-10-CM Official Guidelines for Coding and Reporting and selected entries from Coding Clinic for ICD-10-CM
  • Query processes and procedures
  • Common clinical conditions and indicators for query opportunities
  • CDI program metrics and data analytics
  • Denials management and audit preparedness
  • CDI ethics
  • Pathophysiology for common diagnoses by Major Diagnostic Category

Click here to learn more about prerequisites for taking the exam or to apply.

Published: March 2019

Page count: 144
Dimensions: 8.5x11 spiral bound
ISBN: 978-1-68308-894-3

Table of Contents


  • Purpose of Credential
  • Exam Format

Chapter 1: Rules to Live by for Healthcare Code Assignment

  • The Origins of Healthcare Coding
  • Coding Rules
  • DRGs
  • Assigning a Code
  • Chapter-Specific Guidelines for Code Assignment

Chapter 2: Healthcare Regulations, Reimbursement, and the Inpatient Prospective Payment System

  • IPPS
  • ICD-10 Coding Grouping Mechanisms
  • Contributing Factors to DRG Assignment and Reimbursement
  • Auditor Oversight and Denials Avoidance

Chapter 3: Quality-of-Care Measures and CDI Endeavors

  • Public Report Cards
  • Pay-for-Performance Initiatives
  • The Role of CDI Specialists in Quality Initiatives

Chapter 4: Medical Record Documentation and the Query Process

  • Parts of the Medical Record
  • Query Practices

Chapter 5: Ethical Practices and Effective Communication

  • Ensuring Compliant Processes
  • Government Oversight for Compliant Practices
  • Confidential Information and Ongoing Education

Chapter 6: Anatomy, Physiology, and Pharmacology

  • Identification of Clinical Indicators
  • MDC 1: Diseases and Disorders of the Nervous System
  • MDC 4: Diseases and Disorders of the Respiratory System
  • MDC 5: Diseases and Disorders of the Circulatory System
  • MDC 6: Diseases and Disorders of the Digestive System
  • MDC 7: Diseases and Disorders of the Hepatobiliary System
  • MDC 8: Diseases and Disorders of the
  • Musculoskeletal System and Connective Tissue
  • MDC 9: Diseases and Disorders of the Skin,
  • Subcutaneous Tissue, and Breast
  • MDC 10: Endocrine, Nutritional, and Metabolic
  • Diseases and Disorders
  • MDC 11: Diseases and Disorders of the Kidney and Urinary Tract
  • MDC 16: Diseases and Disorders of Blood and
  • Blood-Forming Organs and Immunological Disorders
  • MDC 17: Myeloproliferative Diseases and
  • Disorders and Poorly Differentiated Neoplasms
  • MDC 18: Infectious and Parasitic Diseases
  • MDC 19: Mental Diseases and Disorders
  • MDC 20: Alcohol/Drug Use and Alcohol-/Drug-induced Organic Brain Disorders
  • MDC 21: Injuries, Poisoning, and Toxic Effects of DrugsMDC 23: Factors Influencing Health Status and Other Contracts with Health Services
  • MDC 24: Multiple Significant Trauma (MST)
  • MDC 25: HIV Infections and AIDS
  • MDC 26: DRGs Associated with All MDCs

Chapter 7: Healthcare Facility CDI Program Analysis

  • Metrics to Measure CDI Programs
  • Productivity Metrics
  • Program Success Metrics


About the Author

Fran Jurcak is an experienced nursing professional who has spent the past 13 years in clinical documentation improvement (CDI). She has used her clinical knowledge and experience to provide education, support process improvement, and report outcomes for CDI programs across the country for JA Thomas & Associates and Huron Consulting Group. For the past three years, she has been employed at Iodine Software, where she is the vice president of clinical affairs and is responsible for clinical services and product development. Jurcak received the 2017 CDI Professional Achievement Award from ACDIS and currently serves on the ACDIS Advisory Board, the Certified Clinical Documentation Specialist (CCDS) credential committee as well as the new CCDS-Outpatient credential committee.