Boost Payer-side Coding Credibility

By Michelle A. Dick, senior editor
For coders in the payer venue, the world is different. They review claims and work in coordination of benefits staff, auditors, utilization management, billing services, provider relations, contracting, or customer service. Payer coders also verify coding accuracy and correct reimbursement. The AAPC has updated the Certified Professional Coder-Payer (CPC-P®) exam and created a new preparation guide to assure you have the skills to address coding issues unique to the payer world.
Settle Payer/Physician Coding Differences
Julia Croly, MPA, CPC, CPC-P, director for Underwriting and Analytical Services, Blue Cross and Blue Shield of North Carolina, said, “The CPC-P® certification solidifies one’s knowledge of the current payer environment and, at the same time, allows us to partner with physicians to attain a goal of seamless claims payment.”
Coding for a payer requires knowledge of payment methodologies and coding expertise that is different from the physician side. Susan Goldsmith, CPC, CPC-H, CPC-P, CPC-I, CCS-P, CCP, CPEHR, owner of SG Consulting Services Inc., Phoenix, Ariz., is an expert on the payer end of coding/billing and acknowledges the unique payer coding requirements. “Coders submitting claims on behalf of physicians use coding conventions to describe all the services the physician provided,” said Goldsmith. “Coders at the payer side, however, must also know how those codes are utilized to determine payments for those services.”
For example, payer-side coders need to know:

  • Rules regarding bundling of services;
  • When to reduce payments for multiple services;
Which services require additional professionals 
(such as assistant surgeons’);
How to determine proper payment for those additional professionals; and
How to identify services that are included in global payments and are not eligible for separate payment.

The CPC-P® credential can help prepare payers to “correctly process claims, review claim patterns to detect inappropriate claiming, review and determine the validity of claim disputes, design payment systems, assist with actuary studies of service utilization, and perform contract administration and data analysis duties,” Goldsmith said.
CPC-P® Moves You Up in the Payer World
If you are coding at a commercial or federal payer, you should consider earning the CPC-P® credential. The CPC-P® credential verifies that a coder “understands how coding translates into proper payment, which can expand a coding professional’s potential employment opportunities within a payer organization,” she said.
The CPC-P® demonstrates the payer coder’s aptitude, proficiency, and knowledge of coding guidelines and reimbursement methodologies for all types of services from the payer’s perspective. AAPC National Advisory Board (NAB) President-elect Jonnie Massey, CPC, CPC-P, CPC-I, AHFI, Legal Division, supervisor, external audit and investigations of the Regence Group, said that the CPC-P® credential helped her professionally by recognizing she has the skills to correctly answer pressing coding and reimbursement issues unique to payers. “In these challenging economic times, demonstrating a willingness to pursue excellence through the CPC-P® credential is vital to both my career and employer. By taking the extra steps to earn this credential, I have demonstrated I am willing to go above and beyond the minimum required work.”
Power-up for the Payer Coding Exam
The CPC-P® Study Guide covers appropriate coding and typical industry standard edits to demonstrate how they work in conjunction with various reimbursement methodologies for physician services, outpatient services, and inpatient services. The study guide also reviews health insurance concepts, HIPAA and concepts related to CPT®, HCPCS Level II, and ICD-9-CM coding.
Practice exams feature 30 questions taken online with immediate test results. Incorrect answers display with correct choice rationales to help you learn. Practice exams emulate the content and difficulty level of the actual exam, so they are a realistic indicator of your readiness. You can take the practice exams as many times as you want until you feel confident to pass the exam.
Goldsmith is developing a three-day workshop course curriculum for individuals planning on taking the CPC-P® exam. For more information, payers may contact her via e-mail at
Test Your Payer Coding Skills
The CPC-P® exam certifies knowledge to adjudicate provider claims effectively. The exam tests coding-related payer functions and how those functions differ from provider coding. The CPC-P® exam:
Is a 5½ hour, open book, proctored exam.
Consists of 150 multiple choice questions separated into two parts: The Medical Coding Concepts section tests the medical terminology, anatomy, and CPT®, HCPCS Level II, and ICD-9-CM coding concepts; and, the Reimbursement Methodologies section covers physician reimbursement, inpatient payment systems, outpatient payment systems, health insurance concepts, and Health Insurance Portability and Accountability Act (HIPAA).
Costs $300 ($260 AAPC students), and you have one free retake if you don’t pass the exam.
Contributing developers of the exam include Dr. Marc Lieb, M.D., J.D., as well as a number of well-known CPC-P®s in the payer community.
Certification Requirements
As of January 2009, all exams are reported with exact scores. The CPC-P® exam will report the top three areas of weakness. A CPC-P® must have at least two years medical coding experience and maintain yearly renewal as well as submit 36 continuing education units (CEUs) every two years for verification and authentication of expertise.
You’ll find more on obtaining and maintaining the CPC-P® credential on the AAPC website.

Certified Professional Coder-Payer CPC-P

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