Certified Documenter in General Surgery
Documentation is key for accuracy to support clinical requirements, coding, and quality measures. The CDGS™ credential is for health care providers, from medical assistants to physicians, to increase their patient care and solidify the practice.
With the Special Coder Institute, all credential exams are fill-in-the-blank. SCI does not utilize the multiple-choice format as real-world coding is not multiple choice.
Those who have earned the CDGS™ credential with the minimum passing score of 90% have shown they are experts in the field of coding for general surgery.
The Certified Documenter in General Surgery™ examinee will be tested on:
Reviewing medical documentation for the highest level of accuracy.
Identify documentation shortfalls in a medical record.
Identify documentation to support the following code sets:
Current Procedural Terminology (CPT®) coding
Global surgery package
100 fill-in-the-blank codes with multiple case studies
3 hours and 0 minutes time permitted
90% or higher score required for exam passing
FREE retake, valid 1 (one) year from purchase date
An examinee must hold current SCI membership.
Exam Approved References
CPT® book (AMA publisher)*
ICD-10-CM (any publisher)
HCPCS (any publisher)
E/M audit sheets
1995, 1997, and 2021 Documentation Guidelines
One additional reference per the examinee's choosing.
*NOTE: Procedural Coding Expert and Procedure Desk Reference books are permitted for SCI exams and may be used in lieu of or in addition to a CPT® book.
The Specialty Coder Institute has created an 8 hour, on-demand, high quality education class to prepare for the exam. Tuition includes textbook. CPT, ICD-10-CM, and HCPCS books are not provided. Class education includes pre-recorded classroom video, PowerPoint video, practice case studies.
Once a member earns the CDGS™ credential, CEUs (continuing education units) are required to maintain membership. For CEU information, visit SCI's CEU page.