CCDS Exam Study Guide, Fifth Edition

Fran Jurcak, MSN, RN, CCDS, CCDS-O
Reviewed by Sharme Brodie, RN, CCDS, CCDS-O, CRC

The first two years of a Clinical Documentation Integrity (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, Fifth Edition has been updated for 2022 and contains all the latest information you will need to sit for the CCDS exam with confidence.

The fifth 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, query practice guidance, 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, Fifth Edition will:

• Help candidates determine whether they are ready to take the CCDS exam
• Prepare qualified candidates so that they can have 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.

Want some more information about the certification process? Watch this free webinar with two of ACDIS' expert CDI education specialists on the topic!

Want a more in-depth preparation option? Take one of our CCDS Exam Prep Boot Camps, virtually or online at your own pace!

Published: July 2022

Page count: 150
Dimensions: 8.5x11 spiral bound
ISBN: 978-1-64535-193-1

Table of Contents

Introduction

• 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
• Factors that Contribute 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, Poisonings and Toxic Effects of Drugs
• Factors Influencing Health Status and Other Contacts With Health Services
• MDC 24: Multiple Significant Trauma (MST)
• MDC 25: HIV Infections and AIDS
• MDC 26: DRGs Associated with All MDCs
• Conclusion

Chapter 7: Healthcare Facility CDI Program Analysis

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

About the Author

Fran Jurcak, MSN, RN, CCDS, CCDS-O, is an experienced nursing professional and has spent the past 13 years in clinical documentation integrity (CDI). She has utilized 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 six 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 supports healthcare systems as they seek to ensure that clinical documentation and medical record processes accurately reflect care provided and resources consumed in patient care. Additionally, Jurcak focuses on creating efficient workflows, preventing duplication of efforts, and supporting professional communication between the clinical and coding teams. She has worked side by side with CDI specialists and coding staff, CDI leaders, and corporate executives to develop workflows and processes that support positive outcomes for healthcare organizations. She received the 2017 ACDIS award for Professional Achievement for her efforts in the CDI profession. She currently sits on the ACDIS inpatient and outpatient CCDS certification boards and is serving a three-year term on the NAHRI Advisory Board.

About the Reviewer

Sharme Brodie, RN, CCDS, CCDS-O, CRC, is a clinical documentation integrity (CDI) education specialist for HCPro, a division of Simplify Compliance, in Middleton, Massachusetts. Brodie serves as a full-time instructor for CDI Boot Camps and a subject matter expert for ACDIS. She has more than 40 years of experience in the healthcare industry, including multiple areas of nursing, and has served in a variety of roles at both large academic and small community hospitals. Prior to joining HCPro, Brodie worked as a consultant providing program audits, implementation advice, and continuing education for CDI departments—including physician education—in various healthcare facilities across the country. She has been responsible for the successful implementation and oversight of a CDI department and the revitalization of a CDI department at a small community hospital. She is the coauthor of The Essential Guide to Supporting Quality Care Measures Through Documentation Improvement and is a frequent contributor of articles to ACDIS’ CDI Journal and CDI Strategies. Brodie has presented nationally at both the ACDIS Conference and the CDI Outpatient Symposium and is a frequent cohost on the ACDIS podcast. Brodie is currently cochair of both the ACDIS Regulatory Committee and the ACDIS CCDS Committee.