CCS Coding Credential:  Bridging the Gap between CDI and Coding

CCS Coding Credential: Bridging the Gap between CDI and Coding


by Mary Beth York, CCS, CCS-P
Senior Associate at Barry Libman Inc. and Libman Education

I recently had the opportunity to work with a team of Clinical Documentation Improvement (CDI) Specialists to help them prepare for the CCS coding credential exam. They were a motivated group both individually for reasons of professional pride as well as an explicit directive by their employer that they take the training opportunity seriously. They worked hard, learned a lot, and everyone who did the work earned their CCS.

The project started when we were contacted by the HIM Director. The Director wanted to improve the overall coding competency of the CDI staff and ensure they were making appropriate and useful contributions to the documentation and coding processes. The Director knew of our CCS Exam Prep program and believed the rigorous training would benefit these staff and increase the value of the CDI program to the institution.

The CCS coding credential indicates mastery-level hospital acute care coding skills. To achieve their CCS, the CDI staff were required to learn the coding systems in detail and understand how to apply the coding guidelines and conventions. Because they had little exposure to CPT coding, that was also a major undertaking.

CDI staff are typically a highly skilled group, mostly nurses, with in-depth clinical knowledge and experience working in hospitals. Often, they are chosen for their good communication skills and detailed understanding of the healthcare system. Because of their background, CDI see the documentation in the record from the perspective of a care-giver. While CDI and coders share a common language (med term) and work in a common tool (the medical record), their approach to the record can be very different.

CDI staff blessed with significant medical knowledge are reading between every line of a medical record and seeing potential for documentation improvement, if only they can get the provider to write it down. To successfully accomplish the CCS, the CDI staff learned to be literal (“If it is not written, it did not happen,” are words a coder lives by) and code only what is provided in the record while strictly adhering to Coding Guidelines and conventions.

The CCS credential and the training required to attain it can provide a bridge between these two worlds and make both professions better at what they do.


6 Choices to Help You Prepare for the CCS Exam – Which is Right for You?
Libman Education offers 6 different ways to help you prepare for the CCS Exam (including 2 options just for CDI Specialists!).

Choose the option that best fits your learning style. Develop the skills you need to pass the CCS! Learn more here.

About the Author

Mary Beth York, CCS, CCS-P, CIC
Mary Beth York has over twenty year's experience in coding, auditing and documentation improvement for hospitals ranging from community to teaching hospitals as well as physician group practices. Mary Beth is the author of Libman Education's highly successful CCS Exam Prep course, as well as Libman Education's highly successful CCA Exam Review course. 

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