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Professional- licensure, reimbursement, other

Reimbursement for CEP
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Hello Otto

As mentioned below, there are no nationally available billing codes that are appropriate for a clinical exercise physiologist to use. However, there may be some regional third party payors that do reimburse for services that we provide as our colleague Mark Patterson describes. The question is how do you get the ball rolling with one of these regional payors so that you can get paid for the work that you do?

In short, you need to build a relationship in which the payor sees that the service you provide has a real and tangible benefit that is worth them spending money on. The payor is looking for a return on their investment. If you can demonstrate that the service you're providing in terms of pain management and wellness advice decreases resource utilization for that patient (e.g. reduced physician office visits or hospitalizations) or has a significant positive impact on their quality of life (e.g. reduced depression) then you're more than halfway there.

If you don't already have this type of outcomes data, you should start collecting it. You may not have a large enough sample size to adequately detect changes, but maybe you can "sell" it to a regional payor as a pilot project, limited in scope, to see if it's worth developing into something larger.
I am currently working at a pain clinic helping seeing patients and giving them wellness advice. We would like to find out a way to bill patients for my services as an exercise physiologist, but it has been difficult to find the right path. Do you know anyone within the CEP I can talk to about this?

Thank you very much for your valuable help

Otto
Hello Rachel and thanks to Clinton for a wonderful reply.

I happen to be one of those unique CEPs in a unique program.

I work for Kaiser Permanente in Colorado and developed a one-on-one clinical program for cardiology and vascular surgery. It went live in late 2006. I do not use any special CPT code. Kaiser Permanente had the vision to see that my proposal was of benefit to the membership. Keep in mind we are "self contained". The physician group contracts exclusively with Kaiser Permanente Health Plan, the specialty departments are also within the health plan. I only see people with Kaiser Permanente insurance.

So while this may not be of much help to you in your specific situation, programs do exist that can work in a clinical setting.

Have a great day!
Hello Rachel- The simple answer is there is no national insurance coverage for one-on-one services provided by a CEP. When you think of insurance coverage, there is the national coverage (Medicare & Medicaid) and private health insurance. Medicare/Medicaid rules are dictated by the Centers for Medicare & Medicaid Services (CMS). They cover services provided by a CEP related to clinical exercise testing, cardiac/pulmonary rehabilitation, and exercise for peripheral arterial diseases; so you can serve as staff in those programs. You can also be reimbursed for diabetes education if you are a Certified Diabetes Educator (https://www.ncbde.org/). In comparison, as I understand it, CMS only covers RDs for counseling of patients with diabetes and renal disease. Private health insurance companies largely use the rules from CMS, but might vary from these, so you might consider contacting your local BCBS and other health insurance providers in your area. Keep in mind that coverage varies by policy within a given health insurance provider. And coverage for a service does not mean it covers the cost of delivering the service nor is it necessarily no cost for the patient. A local insurance provider might be willing to work with you if you have novel programs that they feel would be beneficial for their members. I've heard others have had success doing this. There is very little, if any, data supporting counseling by a CEP and outcomes; so the lack of reimbursement should not be a surprise. -Best wishes.

Hi All,

I work for a multidisciplinary clinic with a MD, RD, PsyD and they are looking for a way/CPT code that they can use to bill insurance for my services. What I do here is mainly behavior based counseling with a little bit of exercise thrown in. My credentials are ACSM CEP and a Masters of Science in Exercise Science.
Thanks in advance for your help!
Rachel
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