Certified Professional Coder-Payer (CPC-P®)

More private and public payers (health plans) are recognizing the value of employing certified coders to process and analyze medical claims for payment. The CPC-P® credential meets the growing demand for certified coders in a payer environment.

The CPC-P® demonstrates a coder’s aptitude, proficiency and knowledge of coding guidelines and reimbursement methodologies for all types of services from the payer's perspective. Contributing developers include Dr. Marc Lieb, M.D., J.D., Susan Goldsmith, CPC, as well as a number of other well-known CPC-Ps in the payer community. Claims reviewers, utilization management, auditors, benefits administrators, billing service, provider relations, contracting and customer service staff can each benefit their practice with the CPC-P® credential.

The CPC-P® certification exam certifies that the successful candidate has the knowledge and skills to adjudicate provider claims effectively. The exam will test the examinee’s basic knowledge of coding-related payer functions with emphasis on how those functions differ from provider coding. The relationship between coding and payment functions will be explored in depth.

The CPC-P Exam

  • 150 multiple choice questions (proctored)
  • 5 hours and 40 minutes to finish the exam
  • One free retake
  • $300
  • Open code book (manuals)

The CPC-P® exam tests coding accuracy and reimbursement methodologies. The CPC-P® tests the examinee understands of medical terminology, anatomy and CPT®, HCPCS Level II and ICD-9-CM coding concepts. The reimbursement methodologies sections test physician reimbursement, inpatient payment systems, outpatient payment systems, health insurance concepts and HIPAA.

The CPC-P® exam thoroughly covers:

Medical Records and Coding

  • 5 questions
  • 1995 and 1997 E/M Documentation Guidelines
  • ICD-9-CM Official Guidelines for Coding and Reporting
  • CPT® coding guidelines and parenthetical notes

Medical Terminology

  • 10 questions
  • Medical terminology for all systems in the human body

ICD-9-CM Volumes I and II

  • 15 questions
  • ICD-9-CM Official Guidelines for Coding and Reporting
  • Diagnoses for all the chapters included in ICD-9-CM
  • Diagnosis questions will also appear in other sections of the exam from the CPT® categories

CPT® Coding

  • 14 questions
  • Evaluation and Management
    • Office/Other Outpatient
    • Hospital Observation
    • Hospital Inpatient
    • Consultations
    • Emergency Department
    • Critical Care
    • Nursing Facility
    • Domiciliary and Rest Homes
    • Home Services
    • Prolonged Services
    • Case Management
    • Care Plan Oversight
    • Preventive Medicine
    • Non-Face-to-Face Services
    • Special E/M
    • Newborn Care
    • Neonatal and Pediatric Critical Care and Intensive Care
    • Complex Chronic Care Coordination
    • Transitional Care Management
  • Anesthesia
    • Time reporting
    • Qualifying Circumstances
    • Physical Status Modifiers
    • Anesthesia for surgical, diagnostic, and obstetric services
  • Surgery
    • Procedures for each of the systems
      • Integumentary
      • Musculoskeletal
      • Respiratory
      • Cardiovascular
      • Hemic and Lymphatic
      • Mediastinum and Diaphragm
      • Digestive
      • Urinary
      • Male Reproductive
      • Female Reproductive
      • Maternity and Delivery
      • Endocrine
      • Nervous
  • Radiology
    • Diagnostic Radiology
    • Diagnostic Ultrasound
    • Radiologic Guidance
    • Mammography
    • Bone and Joint Studies
    • Radiation Oncology
    • Nuclear Medicine
  • Laboratory/Pathology
    • Organ and Disease Panels
    • Drug Testing
    • Therapeutic Drug Assays
    • Evocation/Supression Testing
    • Consultations
    • Urinalysis
    • Molecular Pathology
    • MAAA
    • Chemistry
    • Hematology and Coagulation
    • Immunology
    • Transfusions
    • Microbiology
    • Anatomic Pathology
    • Cytopathology
    • Cytogenetic Studies
    • Surgical Pathology
    • In vivo and Reproductive
  • Medicine
    • Immunizations
    • Psychiatry
    • Biofeedback
    • Dialysis
    • Gastroenterology
    • Ophthalmology
    • Otorhinolaryngology
    • Cardiovascular
    • Noninvasive Vascular Studies
    • Pulmonary
    • Allergy and Immunology
    • Endocrinology
    • Neurology
    • Genetics
    • Central Nervous System Assessments
    • Health and Behavior Assessments
    • Hydration
    • Therapeutic and Diagnostic Administration
    • Chemotherapy Administration
    • Photodynamic Therapy
    • Dermatology
    • Physical Medicine and Rehabilitation
    • Medical Nutrition
    • Osteopathic Manipulative Treatment
    • Chiropractic Manipulative Treatment
    • Patient Education and Training
    • Non-Face-to-Face Nonphysician Services
    • Moderate Sedation

HCPCS Level II Coding

  • 10 questions
  • Modifiers
  • Supplies
  • Medications
  • Procedures performed on Medicare patients

Modifiers

  • 15 questions
  • Proper modifier use with NCCI edits
  • Proper CPT® modifier use
  • Proper HCPCS Level II modifier use

Outpatient Facility Reimbursement

  • 15 questions
  • Adjudication determination based on codes submitted
  • OPPS Payment Methodology
    • APCs
    • Revenue codes
    • Status Indicators
    • Payment Indicators
    • Condition codes
    • Calculation of proper payments (an excerpts from Addendum B is provided on the exam)

Physician Reimbursement

  • 20 questions
  • Adjudication determination based on codes submitted
  • Apply proper coding according to payment policies
  • Provider reimbursement models (eg, fee for service, capitation)
  • Determine proper payment based on patient's insurance coverage
  • Surgical global package
  • RBRVS
  • Unbundling
  • NCCI Edits

Inpatient Reimbursement

  • 20 questions
  • Determine proper payment based on patient's insurance coverage
  • Adjudication determination
  • Length of stay
  • MS-DRG

HIPAA

  • 3 questions
  • Transaction and Code Set Standards
  • Privacy
  • Security

Health Insurance Concepts

  • 13 questions
  • Services covered by Medicare Parts A, B, C, and D
  • Types of insurance (eg, HMO, PPO, HSA)
  • Services covered by Medicaid
  • Non-covered services
  • Coinsurance
  • Copayment
  • Deductible
  • Clean claims

* Medical Coding Salary