1 Newsle tte r, Sum mer 2010 (Vo lum e 3, Issue 3 ) From the President s Desk It is with great honor that I embark on the presidency of the Clinical Exercise Physiology Association (CEPA). I am tremendously proud to serve on a national association that proactively forges partnerships and sponsors initiatives that promote best practices for delivery of care, as well as improve career opportunities for Clinical Exercise Physiologists (CEP). Before I go any further, I would like to recognize Dino Costanzo, our immediate past president, for his leadership and dedication to this association and the profession as a whole. He is one of the founding members of the CEPA from years back and as president, managed the goals of CEPA with resolute determination. Dino was also steadfast in ensuring that legislative activities at the grassroots and federal level continued to be a priority. He will continue to serve on the board as our immediate past-president and Chair of the Journal committee. Entering this third year, we will continue to actively advocate for the CEP among medical professionals, the community and government officials. The more we communicate with and introduce CEPA to these sectors, it will lend visibility to the CEP and help increase access to our professional services. Our professional structure allows us to respond to issues that affect the Clinical Exercise Physiology Association 401 W. Michigan St., Indianapolis, IN (317) , x148 CEPA Newsletter Editorial Team: Matthew A. Saval, MS, RCEP, CCRP Henry Ford Hospital, MI Wanda Koester, MS, RCEP Bloomington Hospital, IN practice of CEP s and CEPA remains devoted to this cause. There are many committees within CEPA, all working in conjunction with each other to advance this profession. We are fortunate to have passionate leaders chairing and serving on the Advocacy, Legislation, Marketing and Membership committees. Additionally, we have dedicated talent heading up our Continuing Education, Webinars, Journal publications, Career resources, and Student resources to provide our members with valuable benefits. You will learn more about their important updates below from these committed volunteers who devote so much time and energy to accomplish first rate results. The amount of advocacy work and legislative activity that this association is producing on behalf of the CEP has been remarkable. That said, strength in numbers is necessary to sustain these efforts and we need your continued support! In order to carry this momentum forward it is important to spread the word and reach all segments of those working in this field. Please ask your colleagues to join and participate in this worthwhile association and recruit a new member today! I thank you for this opportunity to serve CEPA and look forward to another year of continued growth, advocacy and embracing new technologies to enhance the brand identity of CEPA and recognition of the CEP. Stay Well, Kathleen Cahill, MS, RCEP President, CEPA
2 CEPA Newsletter, Summer 2010 Page 2 Legislative Updates On June 4 th, CEPA had its first Day On The Hill (DOTH). Participants were Kathleen Cahill (CEPA President TX, front left), Clinton Brawner (President-Elect MI, back left), Dino Costanzo (Immediate Past-President CT, back right), Aaron Harding (Past Advocacy Co-Chair OR, back center), and Randi Lite (Past President and Legislative Chair MA, front right). We split into two teams and collectively conducted eleven meetings with legislative aides (LA) or correspondents (LC) in our respective congressmen s offices. Associates from Lewis-Burke accompanied each team, including a briefing in the morning and a de-briefing in the afternoon. Our agenda was to educate each office about CEPA and its mission, and to communicate that CEPs have a unique set of skills and a distinct role to play in chronic disease management, and thus in health care reform. We asked each LC/LA to think about ways in which CEPA could be helpful to them as an ally, and to think about potential opportunities for CEPA to work within current legislation and within governmental agencies. We felt that all of the meetings were productive, and that the LA/LC s were very receptive to our message and wanted to be helpful to us. We have a number of promising leads from these meetings, which the legislative committee will follow up on in the coming months. Our first DOTH left us feeling invigorated, with a renewed sense of purpose, and also humbled by the work to be done. In other Legislative Committee news, George Heron has agreed to be the new Chair of the Subcommittee on State Licensure. We are also creating a research arm for the Legislative committee, and Aaron Harding will chair this subcommittee. We invite CEPA members to get involved in the important work of the Legislative committee. Please contact any of us if you have interest! Randi Lite George Heron Aaron Harding Chair, Legislative Committee Chair, Subcommittee on State Licensure Chair, Research Subcommittee Don t miss out on future s from CEPA To ensure that you don t miss out on from CEPA, contact your institution s Information Technology (IT) department. Tell them to allow from IT departments use specialized software to screen out spam . The algorithms used in these programs might block from CEPA. Better safe than sorry, contact your IT department today.
3 CEPA Newsletter, Summer 2010 Page 3 CEPA News Briefs CEPA Goes on the Road! CEPA made it s first visit to the ACSM Annual Meeting in Baltimore June 1 June 5, CEPA leadership staffed the booth and enjoyed talking with many of the 5,000+ attendees. We held a drawing and gave away a free webinar each day of the exhibit. Congratulations to our winners! They were: Reid N., Christine L., and Andre J. Lots of interested individuals signed up to join CEPA while in Baltimore. If you missed us at the meeting and would like to become a member, please visit our website at Look for us at other major ACSM conferences in the future and tell your peers about us! Help us spread the word that CEPA works to advance the profession of clinical exercise physiology. Wanda Koester, MS, RCEP Bloomington Hospital, IN Chair, Marketing Subcommittee No Better Time! The regulatory activity that is happening on both the state and national levels directly affects the Clinical Exercise Physiologist. Don't be left in the dark! Encourage your colleagues to join and be counted in the national directory of Clinical Exercise Physiologists. Log on to and click on the Member Directory to see if those you know are Members yet. If they are not, encourage them to join now! Member Benefits Continuing education credits delivered to your desk through webinars Practice and reimbursement information Legislative toolkit Voice on capitol hill to protect the right to practice Advocating for the profession Student and career resources Get Involved! If you would like to become involved with CEPA, please contact Robert Berry, MS, RCEP, chair, Membership Committee at
4 CEPA Newsletter, Summer 2010 Page 4 Student Corner Katrina Butner, BS, CES, Virginia Polytechnic and State University, VA Greetings! I have returned for a second year as the student representative for CEPA. First, I want to thank Yuri Feito, Katie Gallagher, Kimberly Goodwin, Amy Kirkham, Young Sub Kwon, Céline R. Neefkes, Laura Newsome, Sarah Smith, Mohamed Sirajuddin, and Florence Vicil for their time and involvement over the past year as members of the Student Advisory Committee (SAC). Several committee members have graduated, so I am now looking to create the SAC. The SAC is a group of students, both graduate and undergraduate, who work to provide resources for clinical exercise physiology (CEP) students to help support current education, training and future careers. SAC members will be giving input and assistance in completing a few assignments and projects. This committee is a wonderful way to get more involved in CEPA, to network and meet other students, plus it looks great on your resume! If you are interested in becoming a SAC member, please me at We had a really productive year last year. The CEPA Internship Directory has over 70 sites and the Clinical Exercise Physiology Association (CEPA) Student Group on Facebook has 120 members! This year our goal is to continue to increase the Internship Directory and to add more members to our Facebook page. I am looking forward to the opportunity to work with many of you over the coming year. Please me if you are interested in becoming a member of the SAC. Or, if you ever have any thoughts or suggestions, please don t hesitate to contact me. I will be happy to share your ideas with the executive committee and keep your considerations in mind when voting. Katrina Butner Advance Your Profession! To be an effective and respected voice for Clinical Exercise Physiologists, this Association needs to represent a critical mass of the entire community of CEP s. This is where you can help! You have already shown your commitment to CEPA by becoming a member. Now is the time to encourage your friends and colleagues to become members. Please encourage them to visit and join today Members from 16 countries...cepa is on the move! ACSM s Conference on Integrative Physiology of Exercise will be in Miami Beach, FL September 22-25, Check out to learn about the many sessions of interest to clinical exercise physiologists. It s not too late to register!
5 CEPA Newsletter, Summer 2010 Page 5 A Summary of the CMS 2010 Cardiac and Pulmonary Rehabilitation Coverage Policies How the Rules Affect the Clinical Exercise Physiologist (Part 2: Cardiac Rehabilitation) David E. Verrill, MS, RCEP, FAACVPR, Presbyterian Hospital Pulmonary Rehabilitating Program, NC From its early origins at universities such as Wake Forest and the University of Wisconsin/ Lacrosse, cardiac rehabilitation (CR) has been shown to extend lives, lessen morbidity, and improve quality of life in patients with, or at risk of, cardiovascular disease. The clinical exercise physiologist (CEP) has been an integral component of CR since its inception in the early 1960 s. The previous Centers for Medicare and Medicaid Services (CMS) guidelines for CR left room for individual interpretation and lacked definitive guidelines for program reimbursement. After many painstaking years of discussion and numerous presentations of peer-reviewed research to CMS by a host of agencies including the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), American Heart Association, and many others, CMS implemented a national coverage plan for CR services on January 1, This article presents a summary of the 2010 CMS CR guidelines and is the second in this two-part series. A summary of the pulmonary rehabilitation CMS policy was presented in the CEPA winter newsletter at A more detailed description of the cardiac and pulmonary rehabilitation policies can be found in the 2010 Medicare Physician Fee Schedule rule (PFS) located at and in the 2010 Medicare Hospital Outpatient Prospective Payment System rule located at Check with your local CMS intermediary (e.g., Palmetto, Highmark, Pinnacle) to determine exactly what the CR health care coverage plan states for your individual state. Physician Supervision and Program Location For an in-hospital or on-campus program, the physician must be immediately available and present on the same campus, in the hospital, or in the on-campus provider-based department of the hospital. CMS does not define immediately available by a time parameter. For programs located in an off-campus facility, the physician must be in the provider-based department of the facility and immediately available and accessible at all times. The CMS definition of in the hospital is as follows: areas in the main building(s) of a hospital or Critical Access Hospital (CAH) that are under the ownership, financial and administrative control of the hospital or CAH; that are operated as part of the hospital; and for which the hospital bills the services furnished under the hospital s or CAH s CMS Certification Number (CCN). The CMS definition of a hospital campus is as follows: Campus means the physical area immediately adjacent to the provider s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual basis, by the CMS regional office, to be part of the provider s campus. For CR or Intensive Cardiac Rehabilitation (ICR) programs in a physician s office (i.e., MD-owned), a physician must be in the suite and immediately available during program operation. An on-campus CR program that has access to a physician-run code team meets the immediately available requirement. However, use of 911 alone does not meet the CMS requirement. Calling 911 as back-up for (Continued on page 6)
6 CEPA Newsletter, Summer 2010 Page 6 (Continued from page 5) patient transport is appropriate but does not substitute for the supervising physician. Whatever the location of the program, the physician is not required to be in the room where the CR or ICR is being delivered. Medical Director/Supervising Physician Requirements The medical director is defined as The physician that oversees or supervises the CR or ICR program at a particular site. The medical director is involved in directing the patient s progress in consultation with the CR staff and is certified in BLS or ACLS. The medical director and supervising physician may be the same person, but they do not have to be. The CR program may have co-medical directors and/or different daily supervising physicians. The medical director is not required to scrutinize each patient s medical record, but should be aware of each patient s condition and knowledgeable of each patient s progress throughout CR/ICR. The supervising physician is immediately available and accessible for medical consultations and medical emergencies at all times during services furnished under the CR/ICR programs. The supervising physician has expertise in the management of cardiovascular disease and is licensed to practice medicine in the state where the CR/ICR program is located. Non-physician practitioners such as nurse practitioners (NP) or physician assistants (PA) cannot: 1) provide direct supervision for CR services in lieu of a physician, 2) serve as the supervising physician for the day, or 3) sign the patient s care plan. CMS does not address whether a referral for CR/ICR from a NP/PA is acceptable this issue may be determined by the local CMS contractor. Note: It is recommended that every program keep a specific record of the physician who met the supervisory requirement on any given day to ensure that the program, if audited, can provide appropriate documentation it has met the supervision requirement. CR Staffing CMS recognizes that the CR staff is multi-disciplinary and does not require specific disciplines to be part of that team. Occupational therapists and registered dieticians may be part of this team, but they may not supervise or bill separately for services furnished during CR/ICR sessions. Physical therapists may provide assessments and individualized treatments as part of the CR/ICR program, but CR/ICR should not be billed separately by different providers or practitioners under other benefit categories. (Continued on page 7)
7 CEPA Newsletter, Summer 2010 Page 7 (Continued from page 6) CMS does not require a specific staff-to-patient ratio for CR/ICR. Qualifying Diagnoses The six conditions covered under the previous national coverage determination policy (removed effective January 1, 2010) will continue to be the same diagnoses required for eligibility in a CR/ICR program: 1. Documented diagnosis of an acute MI within the preceding 12 months 2. Coronary bypass surgery 3. Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting 4. Stable angina pectoris 5. Heart valve repair or replacement 6. Heart or heart-lung transplant Duration and Number of CR Sessions To report and bill for one CR session per day, the duration of treatment must be at least 31 minutes. Staff members should document session duration in a way that is most efficient for the program, as CMS does not specify how session duration should be documented. A maximum of 2 sessions per day are allowed. If two sessions are provided in a day, the first session must be at least 60 minutes and the second session must be at least 31 minutes in duration. While exercise is not required for every CR session, some form of aerobic exercise is required each day that the patient participates in CR. Patients are allowed up to 36 weeks to complete up to 36 sessions. Up to 36 additional sessions at local CMS intermediary discretion may be allowed on a case-by-case basis for a total of 72 sessions. There is no maximum on the number of days of exercise per week (all days would be OK). The patient should receive a minimum of one session per week (Note: CMS understands that a patient may miss a week or two of CR on occasion due to illness or vacation and it is advisable that the CR staff document the reason for the patient s absence.). Required CR Components Individualized cardiac risk factor modification includes education, counseling, and behavioral intervention incorporated into the components described below: (Continued on page 8)
8 CEPA Newsletter, Summer 2010 Page 8 (Continued from page 7) The Individualized Treatment Plan (ITP) The ITP is a plan tailored to each individual patient and includes the type, amount, frequency, and duration of items and services furnished under the plan. The ITP is established, reviewed, and signed by a physician every 30 days. For CR, CMS does not stipulate which physician (e.g., medical director, supervising physician, referring physician) must sign the ITP. While CMS does not specifically require that the medical director sign the ITP, the physician who reviews the ITP is expected to be involved in directing the progress of the individual in consultation with the CR staff. The ITP must include the patient s diagnosis as well as a plan for exercise frequency, intensity, modality, and duration. Measurable and expected goals and outcomes are to be implemented within the ITP, as well as estimated timetables to achieve each. Exercise Component Physician-prescribed exercise is defined by CMS as aerobic exercise combined with other types of exercise (strengthening, stretching) as determined appropriate for individual patients by a physician. Psychosocial assessment The patient s psychosocial assessment is a written evaluation of an individual s mental and emotional functioning as it relates to his/her s condition. Common validated quality of life screening instruments (e.g., SF-36, Beck Depression Index) may be used as part of the psychosocial assessment. The patient s response to, and the rate of progression of, psychosocial intervention is measured under the ITP. The psychosocial assessment is part of the ITP and is not billed separately. Outcomes assessment CMS defines patient outcomes as an evaluation of progress as it relates to an individual s rehabilitation and includes: 1) pre- and post-cr measurements based on patient-centered outcomes measured by the physician, and 2) objective clinical measures of exercise performance and self-reported measures of exertion and behavior. The outcomes assessment is part of the ITP and is not billed separately. (Continued on page 9)
9 CEPA Newsletter, Summer 2010 Page 9 (Continued from page 8) Outcomes are measured at the beginning and at the end of the CR program. CMS allows flexibility in determining which outcomes are measured every 30 days (i.e., ITP) vs. which outcomes are measured at the beginning and at the end of the CR program. Outcome measures are determined by the patient s ITP (e.g. body weight, smoking status, functional capacity) and are similar to those required for AACVPR CR program certification. Alternate or additional outcome measures may be appropriate. Billing Codes and Reimbursement Revenue Code: 0943 HCPCS Code Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) HCPCS Code Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) Education and/or counseling are non-exercise required components. There are no CPT codes for CR staff to bill for initial assessments such as 6-minute walk test CMS considers these to be part of the ITP reimbursement: $38.36 with a co-pay of $13.86 for in-hospital based CR programs for both codes (there may be some regional variations in these amounts) The same reimbursement amount applies to outpatient hospital programs because both are within the Ambulatory patient Classification (APC) For physician-owned or free-standing CR programs, CMS reimbursement is calculated differently and is less (low $20 s). Intensive Cardiac Rehabilitation (ICR) Intensive cardiac rehabilitation is defined by CMS as a physician-supervised program that furnishes CR and has been shown, in peer-reviewed published research, that it improves patients cardiovascular disease through specific outcome measurements. This more intensive therapy arose from the earlier work of researchers such as Drs. Dean Ornish and Nathan Pritikin. An ICR program must demonstrate that it has accomplished one or more of the following: Positively affected the progression of coronary heart disease Reduced the need for coronary bypass surgery Reduced the need for PTCA or stenting An ICR program must also demonstrate that it accomplished a statistically significant reduction in 5 or more of the following patient measures from pre- to post-icr: LDL (Continued on page 10)
10 CEPA Newsletter, Summer 2010 Page 10 (Continued from page 9) Triglycerides Body mass index Systolic blood pressure Diastolic blood pressure Need for cholesterol, blood pressure, and diabetes medications Two new billing codes are available for use by CMS-approved ICR sites: 1. G0422: ICR; with or without continuous ECG monitoring with exercise, per session 2. G0423: ICR; with or without continuous ECG monitoring; without exercise, per session Each of the above codes are within the Ambulatory Patient Classification (APC) Program delivery components of the ICR are as follows: A maximum of six sessions per day are allowed. To report one session in a day, the session duration must be at least 31 minutes. Patients are allowed up to 18 weeks to complete 72 one-hour sessions. The patient must participate in aerobic exercise every day. A minimum of one session/week is required. Exercise is not required every session, should the patient participate in more than one session/day. ICR programs are designated through the national coverage determination process. CMS will review each program, including at least one 30-day public comment period, prior to approval. Programs wishing to apply for ICR status are advised to call CMS for further instructions. There are no components of either CR or ICR that are separately billable all aspects are considered to be part of the program. CMS has posted two Proposed Decision Memos (PDM) for these types of CR programs. They have proposed that both programs meet the required criteria for designation as ICR programs. Public comments were due by June 13, CMS will publish a National Coverage Analysis (NCA) (final decision) by August 12, Conclusion The new CMS guidelines present a long-awaited solidified structure for operation and billing of CR programs. The CEP continues to be an integral staff member for delivery of these services. The CEP is trained to prescribe all forms of exercise and educate those with cardiovascular disease and related co-morbidities. The (Continued on page 11)
11 CEPA Newsletter, Summer 2010 Page 11 (Continued from page 10) CEP is also trained to evaluate these patients with either submaximal (e.g., 6-minute walk) or maximal exercise tests (with or without metabolic analysis), interpret and report test results, and perform outcomes assessments (e.g., body fat, QOL, strength, flexibility) to help meet CMS regulations. A large number of CR programs across the country are managed by CEP program directors. In the present health care environment, the services of the CEP are now needed more than ever to assure the highest level of patient care. With the help from organizations such as CEPA and the advent of CEP licensure in states such as Louisiana, as well as those states considering state licensure such as Utah, Massachusetts, and North Carolina, the CEP will continue to be considered an invaluable member of the CR team in programs across the country and throughout the world. References Medicare Physician Fee Schedule rule (PFS) located at: Medicare Hospital Outpatient Prospective Payment System rule located at: American Association of Cardiovascular and Pulmonary Rehabilitation. AACVPR Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 4th edition. Champaign: Human Kinetics, AACVPR Webinar: CMS Final Rules Pulmonary & Cardiac Rehabilitation A Special AACVPR Webinar. November 10, Brief Guide to 2010 Medicare Coverage and Payment of Cardiac, Intensive Cardiac, and Pulmonary Rehabilitation Services. Located at Members Only section.