What Does a CCDS Do?
A CCDS focuses on reviewing and improving the accuracy and completeness of clinical documentation within a healthcare setting. Their primary goal is to ensure that the medical records fully reflect the patient's diagnosis, treatments, and overall care, in line with coding guidelines and reimbursement requirements. CCDS professionals work closely with physicians, medical coders, and other healthcare team members to ensure that the clinical documentation is both accurate and compliant with regulatory standards. Their duties typically include:
• Reviewing medical records to identify missing or unclear documentation.
• Collaborating with physicians and healthcare providers to enhance the clarity and detail of medical records.
• Educating providers on best documentation practices.
• Ensuring compliance with regulatory requirements like HIPAA, CMS, and ICD-10 guidelines.
• Conducting audits and assessments to identify gaps in documentation and coding.