Top 11 Clinical Documentation Specialist Certifications

Certifications are an important way for a clinical documentation specialist to demonstrate their knowledge and expertise in the field. Having certifications shows that a clinical documentation specialist has taken the time to learn about the latest trends, best practices, and regulations in healthcare documentation. This can help them stand out from other candidates when applying for jobs and can also be used as proof of their qualifications when negotiating salaries. Certifications also provide a great opportunity for continuing education, which is essential in a rapidly changing healthcare landscape. By staying up to date on new developments, clinical documentation specialists are better equipped to accurately document patient care and ensure compliance with regulatory requirements.

The purpose of this article is to review the top certifications for Clinical Documentation Specialists and explain how they can contribute to a successful career in the field.

What are Clinical Documentation Specialist Certifications?

Clinical Documentation Specialist Certification is a specialized certification designed to recognize professionals who have achieved the highest standards of excellence in the field of clinical documentation. This certification is offered by the American Health Information Management Association (AHIMA) and is recognized as one of the most prestigious credentials in the healthcare industry. Clinical Documentation Specialists are responsible for ensuring that patient records accurately reflect clinical services provided, while also ensuring timely and accurate coding and billing processes. This certification demonstrates an individual's mastery of medical record documentation and coding, as well as their knowledge of reimbursement systems, quality assurance guidelines, privacy regulations, and other regulatory requirements.

By earning this certification, Clinical Documentation Specialists demonstrate their commitment to professional excellence and gain recognition for their expertise from employers, colleagues, peers, and patients. The credentialing process includes passing a comprehensive exam that tests an individual's knowledge in all areas related to this specialty. In addition to providing recognition for individuals who have reached a high level of proficiency in this field, having this certification can also open up new career opportunities for those looking to advance their career or transition into a new role within healthcare.

Pro Tip: Before pursuing clinical documentation specialist certification, make sure to research the various certifications available and determine which one best fits your educational background and career goals. Additionally, take the time to review the exam requirements for each certification and ensure that you have a good understanding of the topics covered in the exam. Lastly, consider obtaining additional training or education related to the field of clinical documentation to ensure that you are fully prepared for your certification exam.

Related: What does a Clinical Documentation Specialist do?

Top 11 Clinical Documentation Specialist Certifications

Here’s our list of the best certifications available to Clinical Documentation Specialists today.

1. Certified Clinical Documentation Specialist (CCDS)

A Certified Clinical Documentation Specialist (CCDS) is a healthcare professional who specializes in the review, analysis and improvement of clinical documentation. They are responsible for ensuring that the medical record accurately reflects the patient's diagnoses, procedures, treatments and outcomes. The CCDS credential is awarded by the American Health Information Management Association (AHIMA).

It typically takes between six months to a year to become certified as a CCDS. To obtain certification, candidates must pass an exam administered by AHIMA. This exam consists of multiple-choice questions and covers topics such as coding principles, clinical documentation improvement strategies and quality management. Candidates must also have at least two years of experience in either HIM or CDI to be eligible for certification.

The cost of becoming certified as a CCDS varies depending on the individual's location and other factors. Generally speaking, it costs around $400-$500 USD to take the exam and receive certification.

2. Certified Professional Medical Auditor (CPMA)

A Certified Professional Medical Auditor (CPMA) is a professional certification that demonstrates an individual’s expertise in the field of medical auditing. The CPMA certification is offered by the American Academy of Professional Coders (AAPC), and it is designed to recognize individuals who have demonstrated mastery of medical audit principles, processes, and techniques.

The CPMA exam consists of 150 multiple-choice questions covering topics such as health care compliance, risk management, data analysis, coding accuracy, and reimbursement policies. The exam takes approximately three hours to complete.

To be eligible for the CPMA exam, applicants must have at least two years of experience in medical auditing or a related field. Applicants must also pass a criminal background check prior to taking the exam.

The cost to take the CPMA exam is $399 for AAPC members and $499 for non-members. The cost includes access to study materials and practice tests.

3. Certified Professional Coder (CPC)

Certified Professional Coder (CPC) is a certification that is offered by the American Academy of Professional Coders (AAPC). It is designed to certify individuals who have achieved a high level of proficiency in medical coding. The CPC certification demonstrates an individual’s knowledge and competency in medical coding and billing, as well as their commitment to ethical standards.

It typically takes between 6-12 months to prepare for the CPC exam. Preparation includes studying the materials provided by AAPC, attending seminars or workshops, and taking practice exams.

To become certified, individuals must pass the CPC exam. The exam consists of 150 multiple-choice questions that cover topics such as anatomy, physiology, medical terminology, ICD-10-CM diagnosis codes, CPT procedure codes, HCPCS Level II codes, and modifiers.

The cost of becoming certified varies depending on the type of membership you choose with AAPC. A standard membership costs $199 per year plus an additional $399 for the exam fee.

4. Certified Healthcare Documentation Specialist (CHDS)

A Certified Healthcare Documentation Specialist (CHDS) is a professional who specializes in the accurate and timely documentation of patient health information. This includes medical records, reports, and other forms of communication between healthcare providers, patients, and their families. The CHDS credential is awarded by the American Health Information Management Association (AHIMA).

To become a Certified Healthcare Documentation Specialist, individuals must first complete an accredited program in health information technology or health information management. After completing the program, they must then pass the CHDS exam administered by AHIMA. The exam consists of two parts: a written knowledge assessment and a performance-based simulation.

The cost to take the CHDS exam varies depending on where you take it. Generally speaking, the fee ranges from $225 to $400 USD. It typically takes about three months to prepare for the exam and receive your results. Once you have passed the exam, you will be awarded your CHDS certification which is valid for three years before needing to be renewed.

5. Certified Documentation Improvement Practitioner (CDIP)

Certified Documentation Improvement Practitioner (CDIP) is a certification offered by the American Health Information Management Association (AHIMA). It is designed to recognize individuals who have achieved a high level of expertise in coding, documentation, and compliance for healthcare organizations. The CDIP certification validates an individual’s knowledge and skills in the areas of clinical documentation improvement, coding accuracy, data quality management, and reimbursement optimization.

It takes approximately one year to complete the CDIP program. During this time, individuals must complete an online application and submit evidence of their education and experience in the field. Once accepted into the program, they must complete a comprehensive exam that covers topics such as medical terminology, anatomy and physiology, coding systems, clinical documentation improvement principles, legal issues related to healthcare documentation accuracy and compliance with government regulations.

In order to maintain their certification status, CDIPs must participate in continuing education activities every two years. They also need to demonstrate that they are current on changes in healthcare regulations and industry standards.

The cost of obtaining the CDIP certification varies depending on the individual's experience level and educational background. Generally speaking it can range from $500-$1000 USD for all required materials including books, exams fees etc.

6. Registered Health Information Technician (RHIT)

A Registered Health Information Technician (RHIT) is a professional who specializes in the maintenance and management of health information data. This includes patient records, medical coding, billing and reimbursement systems, quality assurance methods, and other related tasks. RHITs are responsible for ensuring the accuracy and security of patient health information.

To become an RHIT, you must first complete an associate’s degree program in health information technology from an accredited college or university. These programs usually take two years to complete and include courses such as anatomy and physiology, medical terminology, coding systems, healthcare regulations, computer applications, and more. After completing the degree program, candidates must pass a certification exam administered by the American Health Information Management Association (AHIMA).

The cost of becoming an RHIT varies depending on the school you attend. Tuition costs can range from $5,000 to $20,000 per year depending on the institution. Additionally, there is a fee to take the certification exam which is currently $199 for AHIMA members and $299 for non-members.

7. Registered Health Information Administrator (RHIA)

A Registered Health Information Administrator (RHIA) is a professional credential that certifies an individual's expertise in managing patient health information and medical records. It is awarded by the American Health Information Management Association (AHIMA) and is one of the most respected credentials in healthcare.

To become an RHIA, you must have a minimum of an associate degree in health information management or a related field, plus additional coursework in health data analysis, coding systems, and other healthcare-related topics. You must also pass the RHIA certification exam administered by AHIMA. The exam consists of multiple choice questions and takes approximately four hours to complete. Once you pass the exam, you will be officially certified as an RHIA.

The cost for taking the RHIA certification exam varies depending on your location and whether or not you are a member of AHIMA. Generally speaking, it costs between $350-$400 USD to take the exam. Additionally, there may be fees associated with registering for the exam and/or renewing your certification every two years.

Overall, it typically takes around two years to become an RHIA if you are starting from scratch with no prior experience in healthcare or health information management. However, if you already have some experience in this area, it may take less time to become certified as an RHIA.

8. American Health Information Management Association (AHIMA) Certification

The American Health Information Management Association (AHIMA) is a professional organization for health information management (HIM) professionals. AHIMA certification is a voluntary credential that demonstrates an individual’s knowledge, skills, and abilities in the field of HIM. It provides recognition from peers and employers of the individual's commitment to the profession.

AHIMA offers several different certifications depending on the individual’s level of experience, including Registered Health Information Administrator (RHIA), Certified Coding Specialist-Physician Based (CCS-P), Certified Documentation Improvement Practitioner (CDIP), and Certified Tumor Registrar (CTR).

It typically takes six months to two years to obtain AHIMA certification, depending on the type of certification being sought. To get certified, individuals must pass an exam administered by AHIMA. The cost of certification varies depending on the type of certification being sought. Generally speaking, it costs between $300 and $500 for most certifications.

9. Medical Records and Health Information Technician Certification

Medical Records and Health Information Technician Certification is a credential that demonstrates an individual’s knowledge and skills in the field of medical records and health information technology. This certification is offered by the American Health Information Management Association (AHIMA).

To obtain this certification, individuals must pass an exam that covers topics such as coding systems, data management, health information technology, privacy and security regulations, and healthcare reimbursement. The exam consists of 150 multiple-choice questions that must be completed within three hours.

The cost to take the exam varies depending on whether the individual is an AHIMA member or nonmember. For members, the fee is $229; for nonmembers, it is $329. Additionally, there are study materials available for purchase from AHIMA which can help prepare for the exam.

The amount of time needed to prepare for the exam will vary depending on how much experience a person has in medical records and health information technology. Generally speaking, it may take several months of studying before taking the exam.

10. Certified Electronic Health Record Specialist (CEHRS)

Certified Electronic Health Record Specialist (CEHRS) is a certification program offered by the National Healthcareer Association (NHA). It is designed to recognize individuals who have achieved a high level of proficiency in electronic health record systems. This certification demonstrates an individual's ability to use, manage and maintain EHR systems, as well as understand the legal and ethical implications of using these systems.

The CEHRS certification requires applicants to pass an exam administered by the NHA. The exam consists of 150 multiple-choice questions covering topics such as information technology, data security, privacy and confidentiality, healthcare regulations, and workflow processes. To be eligible for the exam, applicants must possess at least two years of experience working with EHR systems or have completed an approved training program related to EHRs.

The exam typically takes three hours to complete and costs $199 for NHA members or $299 for non-members. Once the exam is successfully passed, a CEHRS certification will be issued that is valid for two years from the date of issuance. After two years, individuals must renew their certification by passing another exam or completing continuing education credits in order to maintain their credential.

11. American Academy of Professional Coders (AAPC) Certification

The American Academy of Professional Coders (AAPC) Certification is a professional certification for medical coders. It is the most widely recognized coding certification in the healthcare industry and is designed to demonstrate knowledge and proficiency in medical coding.

To obtain AAPC Certification, applicants must pass an exam that covers topics such as anatomy, physiology, medical terminology, ICD-10-CM/PCS coding systems, HCPCS Level II coding systems, and CPT coding systems. The exam consists of 150 multiple choice questions and has a time limit of four hours.

To prepare for the exam, applicants can take advantage of AAPC’s online study materials which include practice exams, webinars, and other resources to help them pass the exam. Applicants may also choose to attend one of AAPC’s live or online training courses to further their understanding of medical coding.

The cost for taking the AAPC Certification Exam varies depending on whether you are an AAPC member or not. For non-members, the cost is $399; for members, it is $299. Additionally, there is a $50 fee for retaking the exam if needed.

Once applicants have passed the exam they will be awarded their AAPC Certified Professional Coder (CPC) credential which is valid for two years from the date of passing the exam. To maintain their CPC credential after two years they must complete continuing education units (CEUs).

Do You Really Need a Clinical Documentation Specialist Certificate?

The answer to this question depends on your individual circumstances and career goals. A Clinical Documentation Specialist Certificate may be beneficial for those who are interested in a career in the health care field or who want to demonstrate their expertise in clinical documentation. It can provide an edge over other applicants in the job market and can help you stand out from the competition.

A Clinical Documentation Specialist Certificate can provide a valuable credential that demonstrates your knowledge and skills in medical coding, review of patient records, and other related tasks. It can also provide recognition as a specialist in the field, which is important for employers looking to hire qualified personnel. Those with a certificate may be more likely to be considered for higher-level positions or more specialized roles within their organization. Additionally, having a certificate may make it easier to transition into different areas of healthcare such as billing or medical administration.

In some cases, employers may require a Clinical Documentation Specialist Certificate before they will consider someone for employment. If you are considering applying for such positions, obtaining a certificate could be essential for your success as a candidate. Additionally, if you plan on working as an independent consultant or contractor, having a certification could be beneficial when negotiating rates with potential clients or employers.

Ultimately, whether or not you need a Clinical Documentation Specialist Certificate will depend on what type of work you plan to do and what qualifications are necessary for those positions. Consider researching the requirements of any jobs you might apply for so that you can make an informed decision about whether obtaining this certification is right for you.

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FAQs About Clinical Documentation Specialist Certifications

1. What is a Clinical Documentation Specialist Certification?

Answer: A Clinical Documentation Specialist Certification is a credential that demonstrates an individual’s expertise in the field of clinical documentation. It signifies that the individual has met certain standards and qualifications, including formal education and experience in medical record-keeping, coding and billing, and medical terminology.

2. What are the benefits of obtaining a Clinical Documentation Specialist Certification?

Answer: Obtaining a Clinical Documentation Specialist Certification can help individuals gain more credibility with employers, increase their knowledge base in the field, and open up more job opportunities. Additionally, having this certification can show potential employers that you are committed to continuing your professional development and staying up to date on new trends in clinical documentation.

3. How do I obtain a Clinical Documentation Specialist Certification?

Answer: To obtain a Clinical Documentation Specialist Certification, individuals must meet certain educational requirements such as completing an accredited program or coursework related to clinical documentation. Additionally, individuals must pass an examination administered by either the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).

4. How long does it take to get certified as a Clinical Documentation Specialist?

Answer: The amount of time it takes to get certified as a Clinical Documentation Specialist varies depending on an individual’s experience level and education background; however, it typically takes between six months and two years to complete all necessary training and examinations required for certification.

5. Are there any continuing education requirements for maintaining my certification?

Answer: Yes, all certified Clinical Documentation Specialists must complete at least 20 hours of continuing education every two years in order to maintain their certification status. Continuing education credits can be obtained through attending seminars, conferences, workshops or webinars related to clinical documentation topics such as coding updates or HIPAA compliance changes.