For many exercise professionals, the goal of training and educating clients is to improve health, increase strength and performance, and improve fitness parameters. The concept of reducing injuries may not be high on their radar screens.
I am reading a recent article by Jonathan Mike (in PFP Winter 2019 issue) regarding scope of practice for personal training. I feel that I should respond to this for a couple of reasons – first to add some clarity to his foundation of SOP in wellness, and second…
In July, I had the opportunity to deliver a webinar for MedFit Network on data analytics and population health for the medical fitness profession. I believe the MFN is spot on in their interest in data, and here’s why….
There are three distinct areas of exercise as it relates to healthcare – and reimbursement. Most trainers and fitness professionals are aware of cardiac rehab, which actually began in the US in the 1960s, but gained ground as a reimbursable health care service in the 1980s. At that time there was a lot of good exercise and sports medicine research available in peer reviewed publications, and there was a push on the part of health care to include cardiac rehab as part of rehab and health promotion services. The fact that most cardiac programs were reimbursed up to 36 sessions was a plus.
The second area of healthcare that is relatively new is the Silver Sneaker’s program – started in Arizona in 1994, it quickly grew to the nation’s leading reimbursable wellness program for seniors. It was accepted by Medicare Plus
Choice, and a host of other health plans across the nation – so that within a few years of its inception, seniors from anywhere in the US could take advantage of free exercise and health classes at area health clubs, YMCAs, and JCCs. The program was recently sold to Healthways health systems from Nashville for over $400 million – a testament to the interest of such programs within the healthcare industry.
The third area is the use of exercise therapy in worker’s compensation programming. Over the past decade there are some significant programs implemented that contract with large employer groups and HMOs to use exercise both in a preventive and therapeutic format. These programs include strength and aerobic training geared to improve functional strength, reduce WC costs and reduce lost work days. Clearly these areas of clinical exercise have set a precedent regarding both the use of fitness programs in healthcare, and reimbursement for these programs through third parties.
Enter Cancer Wellness. There were few programs for cancer survivors for any type of health program in the early 1990’s. A few health clubs and hospitals had specialty exercises for persons with cancer, but programs really started to grow when Dr. Meryl Winningham from University of Utah began publishing the first sports medicine research in the field in the 1980’s (which became more widely read in the mid 1990’s), and champion cyclist Lance Armstrong made his remarkable comeback from cancer in the late 1990’s. Over the past decade the number of health clubs and hospital wellness centers that offer cancer exercise programs has grown exponentially. There are now hundreds of programs in existence nationally – in clubs, private training centers, Pilates studios, and hospitals. More are interested, but the main question remains – is this program reimbursable?
For those in health promotion who haven’t noticed – reimbursement has changed dramatically in the past 10 years. Programs that historically received reimbursement (such as cardiac rehab), have been cut dramatically (while, ironically, cardiac operations and prescription medication costs have escalated three-fold). However – that doesn’t mean that reimbursement doesn’t exist for health programs, you just have to know where to look. An example is smoking cessation classes. Instructed by counselors and physician assistants, most of the reimbursement for these classes (and nicotine replacement therapy) is funded by state tobacco settlement grants and initiatives, which is very helpful in terms of passing along savings to patients.
Is reimbursement possible for cancer wellness? Select groups from areas in the US are working with local health plans, or pharmaceutical companies to capture their markets in terms of offerings to patients. For those who are interested in looking towards reimbursement for their program – here is some advice for getting started:
- Find out how many persons in your region are cancer survivors. Your local cancer treatment center should have statistics. Most areas have well over 1,000 new cases per year. You may also market to persons who have had cancer diagnosed years before. They may still attend support groups, or be on mailing lists from the same cancer centers.
- Establish a relationship with a local oncologist or treatment center. You may be able to hold exercise programs on-site and bill through your community local oncology or rehab clinic. This is similar to billing for group therapy or physical therapy. However – it should be remembered that this is a wellness program, and there are specific wellness codes that physicians and billing departments can bill under.
- Know your billing codes. In order to receive any form of reimbursement – you should know the system you are working in. There are resources that may assist you in learning coding for wellness programs, and you should take advantage of them (see resource section).
- Know what outcomes you are interested in reporting. For many cancer patients, a reduction in lymphedema, less pain and fatigue, and increases in fitness parameters are an excellent way to show that the program is working well. Improving these outcomes will also boost attendance, which is another important aspect of the program (compliance).
- Look for local sponsors. A proposal to local pharmaceutical reps may increase your odds of receiving reimbursement – through a third party such as a pharma company. They often set aside money in their budgets for health programs, and cancer wellness may fit the bill very well.
What to do once you’re up and running? In the first year it’s important to have a working budget. This may only lend itself to 3-5 patients coming to your program to start. Once they experience the benefits of exercise and wellness, they will quickly tell their fellow patients. It’s also important to spread the word via small group lectures and fitness demonstrations. Since most cancer centers have monthly support groups, it’s a great place to conduct a 30 minute lecture and demonstration for local survivors. Next – a couple of sample articles for the local newspaper (perhaps a series) on the benefits of exercise for cancer survivorship. There are new research reports out each month. Lastly – call your local radio show and book a time to discuss exercise for cancer survivorship. They would love to have a topic like this for their time slots.
The initial year is a “make or break” one for survivor programs. In my experience with many of my national programs – those that got some funding, and did some promotion have programs that have grown. Those who relied solely on patient membership fees in many cases have not been able to grow their programs. Funding is important, and reimbursement may be a part of patient’s health plans, so it would benefit you to contact local health plan reps to see if they cover the cost of post rehab exercise, and/or health club membership for their members.
Cancer Wellness is one of a handful of growing wellness programs in this country that health specialists AND physicians are looking to for avenues of increased reimbursement, or sponsorship. There are many local and regional resources (cancer treatment centers, non profit organizations and foundations, pharmaceutical companies, and regional HMOs) that may be interested in funding such programs. It is up to you to start looking for financing as you start your education program. This will ensure future success at both the educational AND financial levels.
Written by Eric Durak, Medical Health and Fitness ©2011-2014. Eric Durak is the President of Medical Health and Fitness, and Director of the Cancer Wellness CEU Program in Santa Barbara, CA. He is also the author of The Reimbursement Book for Health and Fitness Instructors . Contact him at email@example.com / 805-451-8072. www.medhealthfit.com
Durak, EP. The important link between exercise and cancer. ACE Matters. Pg. 13, Sept. 1999
Author – Exercise reduces cancer treatment side effects. Health News. 12(9):pg.8, 2006
Jones, LW, Denmark-Wahnefried, W. Diet, exercise, and complementary therapies after primary treatment for cancer. Lancet Oncology. 7(12):1017-26, 2006.
Korstjens, I, Mesters, I, et al. Quality of life of cancer survivors after physical and psychosocial rehabilitation. European Journal of Cancer Prevention. 15(6): 541-7, 2006.
Looking at the Use of CPT Coding for the Wellness Profession. A Revised Look at Integration of Health Promotion within Healthcare.
It has been over 24 years since I wrote my first book on Medical Insurance Billing for the Health and Fitness Profession. The book was based on my years as an exercise therapist who used CPT coding for sessions with diabetic patients. Our use of proper billing, follow up letters, and reasonable pricing allowed our physician practice to bill out for some exercise sessions for over two years.
I have been asked recently to discuss the issue of reimbursement in our current system. Over the past 50 years the system has worked for physicians, and some allied health professionals, who have developed procedures that they will get paid for – and they usually perform specific types of services within their practice that allow them maximum reimbursement.
The times are changing, though. As they have since the mid 1990s when managed care tried to curb the amount of fee for service payments for specific services. If you talk with physical therapists, you would see that they have been concerned over a decade that they are unable to bill for the same amounts per service that they once did. A sign of the times? Perhaps – but in the wellness profession we need to dig a bit deeper to see how the system (that is not built for us) can work for us.
Billing for a Fee For Service Method
All healthcare agencies that use CPT coding to some degree. How they use them is a different situation. Some medical practices will submit bills to CMS or health plans and wait for payment. It is based on where they live, and what these agencies pay on an average for the particular service. Medical professionals will “bundle” a number of different procedures together for each payment in hopes of getting a higher payout. However – using CPT codes are also valuable for health promotion professionals to understand the “language” of health care. Let’s look at some examples of how these codes may work well for wellness programs.
Success Stories in Contracting
Perhaps one of the biggest success stories of working with healthcare is the Silver Sneakers program. They don’t bill directly for FFS – they have used specific CPT codes to negotiate for contracts for their wellness programs. Another example is Wellquest – the east coast company that competed in the senior wellness space with Silver Sneakers. They were also successful in negotiating contracts with regional health plan. They didn’t use CPT codes – but specific types of programming to convince health plans to buy into their model. There are a few companies that use versions of coding to help injured athletes come back to work. One is the Industrial Athlete in Detroit, MI. This company has been delivering preventive and therapy services to companies since 1989. Companies look to specific CPT codes to detail the particular type of program they are delivering. Of course – they may want to know what type of reimbursement is being delivered in their area, but many in the health club setting look to costs of personal training, which may range from $30-150 per session depending on the location. Let’s look at the types of codes that have been historically been used for exercise-related services. There are other worker’s compensation programs that are billing directly for personal training with staff that have been to the Occupational Medicine doctors, and now want to get back to work. With chronic exercise, many of them reduce their risk for future back injuries by almost 100%.
What are the Codes?
When I started investigating CPT billing codes, I uncovered what I thought was the Holy Grail for many allied healthcare personnel. They thought that because they studied an allied healthcare curriculum in school, and passed a state board licensure exam – they were entitled to receive reimbursement based on these skills. However – when I spoke with the American Medical Association (the national body that owns the © the CPT codes used by all healthcare professionals), I received a different story. The codes are merely descriptors of services. They are copyright of the AMA, and they are licensed to others to use them directly. For our purposes, we will be discussing CPT codes that have to do with exercise therapy, and some health education procedures.
Exercise therapy falls under the physical medicine section of the CPT coding book. They may be used for exercise prescription if an MD or other licensed professional wishes to incorporate these services in their practice. Specific codes for these services are as follows:
*Physician or therapist is required to have direct patient contact.
97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion, and flexibility. This code is used for limited visits, such as exercise training for rotator cuff therapy, or general use of aerobic machines. This type of training may encompass a one or two-week period, and be billed out ≈ 3-5 times.
97112 – Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, & proprioception. This code is used primarily by Physical Therapists and Massage Therapists for patients with neuromuscular deficits that require movement along with physical manipulation of body parts (along with pressure point work, etc.). This code would not be used for therapeutic exercise procedures, but specific movement programs such as shoulder or hip movement post stroke, or shoulder movements post breast cancer surgery.
97113 – Aquatic therapy with therapeutic exercises is used for any therapeutic activity involving water. Aquatic therapist and inventor of the Hydro-Tone equipment Dan Solloway of Oklahoma used this code for all of his work with patients referred to him for aquatic exercise therapy for over two decades.
97116 – Gait training is again used for persons who have orthopedic limitations with movement. It is used infrequently (or not at all) by most exercise therapists, but could be used in the expanding market of senior gait and balance prevention exercises.
97150 – Therapeutic procedure(s), group (2 or more individuals). This code is used for classroom programs, such as T’ai Chi, yoga, chair aerobics, therapeutic step classes, etc. This is designed for practitioners who teach in the group setting – especially with special population classes. One of the top codes that could be used in wellness.
97530 – Therapeutic activities, direct (1 on 1) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes. It replaces the old Kinetic Activities code that was used primarily for exercise therapy procedures. This code should still be used most by exercise therapists for 2-4 segments of 15 minutes each
97535 – Self care/home management training (e.g., activities for daily living [ADL] and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct 1 on 1 contact by provider, each 15 minutes. This code is used primarily in the PT/OT settings, where patients need to regain day-to-day skills, as opposed to general strength and aerobic capabilities. Community Training (97537) is an extension of the self-care coding used primarily by PT and OT. However – now that more trainers and coaches are training in the home, this code may have a benefit relating to home care fitness and wellness programs.
97537 – Community/work reintegration training (i.e.: shopping, transportation, money management, vocational activities and/or work environment/modification analysis, work task analysis), direct 1 on 1 contact by provider, each 15 minutes.
97545 – Work hardening/conditioning; initial 2 hours. It is used for applying exercise to rehabilitate a person after an injury or accident, allowing return to competitive employment. The role of the exercise specialist would be to provide specific work-related exercises, and education principles to patients in these rehab settings (low back, carpel tunnel syndrome, lifting techniques, etc.).
97546 – Work hardening/conditioning; each additional 1-hour
97750 – Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes. It is used to measure strength and aerobic performance, and should be used for all testing procedures that do not require physician supervision or monitoring equipment (such as ECG). This is a good code to use for pre and post testing.
90900 – Biofeedback training; by electromyogram application (e.g., in tension headache, muscle spasm) is used by persons applying low intensity exercise and breathing techniques (Ayurvedic medicine, Hatha yoga, etc.) using EMG applications in the clinical setting. It is used by some exercise physiologists who perform relaxation exercises with patients.
90904 – Blood pressure regulation (e.g., essential hypertension) may be used for programs that offer stress reduction for hypertensive patients. Does not have to include monitoring equipment, but would necessitate improvements in BP control over time independent of pharmacological agents.
93015 – Cardiovascular stress test using maximal or sub-maximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report. It is used for cardiac and pulmonary testing, using ECG and monitoring equipment, physician supervised. This code should be used in the clinical exercise setting when performing testing services on patients who are involved in cardiopulmonary rehab services.
96150 – Health behavior assessment (e.g. – health focused clinical interview, behavioral observations, health-orientated questionnaires), each 15 minutes, face-to-face – initial assessment. Mostly for counselors, but could be used with health coaching programs.
Where is the Future?
Since reimbursement is harder to obtain for most licensed health care practitioners – it certainly won’t be something that anyone in the exercise community will be able to obtain simply by becoming licensed or accredited. The system is in a transformation mode. Most of the methods for obtaining reimbursement or contracting dollars will come from outcomes-based programming. Companies such as Optum are moving into this realm by their executive summaries relating to data analytics, outcomes, and ROI. Health and fitness professionals should do well to read the recent report by Marshall et. al. on outcomes in the health club setting. It has set the stage relating to the opportunities to work with clinical populations, and sets the stage for developing relationships with third party payors through a contract mechanism that will satisfy the needs of both parties.
CPT codes are the language of health care procedures, and they were made for physicians. However – that language can help health and wellness professionals to negotiate contracts that will help pay for memberships, personal or group training, nutrition, and mind/body health programs through the health club industry. After 25 years – I think that the disruption in the health care industry is big enough that smart health club companies and training programs will be able to offer comprehensive wellness services that will be reimbursed at some level. We see it as the next logical step in the progression of the industry.
Reprinted with permission from Eric Durak.
Eric Durak is President of Medical Health and Fitness, and has been involved with exercise and health care since the 1980s. He has worked with the insurance billing system with both physicians and physical therapists. He is the author of over 20 books on health and wellness, one being the Fitness and Healthcare Reimbursement Guide.
- Durak, EP, Shapiro, AA. The Fitness and Healthcare Reimbursement Guide. 7th edition, 2016. Medical Health and Fitness Publishers, Santa Barbara, CA
- Towards Better Outcomes. Optum Executive Summary Report. Optum.com/frostreport. 2016.
- Marshall, TF, Groves, JR, Holan, GP, Lacamera, J, Coudhary, S, Pietrucha, RJ, and Tjokro, M. Feasibility of Community-based Supervised Exercise Programs to Engage and Monitor Patients in a Post-Rehabilitation Setting. 2018. Am. J. Lifestyle Med. 13(1):DOI: 10.1177/1559827617750385
- Nieves, PN. How a synchronized approach addresses key drivers of change in the industry. Optum.com report, 2016.
Disclaimer: Medical Health and Fitness and the American Medical Association are not responsible for any claims filed by individuals or group practices using the five-digit numeric Physician’s Current Procedural Terminology, 6th Edition codes, service descriptions, instructions and/or guidelines are copyright as part of the publications of CPT as defined in the Federal Copyright Law, American Medical Association. All rights reserved. CPT (current procedural terminology) is a listing of descriptive terms and five-digit numeric identifying codes and modifiers or reporting medical services performed by and for physicians.
This representation includes only CPT descriptive terms, identifying modifiers for reporting medical services and procedures selected by Medical Health and Fitness for inclusion in this publication. The most current edition is available from the American Medical Association. No fee schedules, conversion factors, or scales or components are therefore found in CPT.
Medical Health and Fitness has selected certain CPT codes and service procedures descriptions and assigned them to various specialty groups of a CPT service or procedure descriptions and its code number in this publication not restrict its use to a particular specialty group.
Any procedure in this publication may be used by designated the services by a qualified health professional. “The American Medical Association assumes no responsibility for the consequences attributable to or related to an use of or the interpretation of any information contained or not contained in this publication”.
A recent report in Forbes Magazine by writer Unity Stokes discusses the recent issues concerning the validity of blood tests results from a Silicon Valley lab company called Theranos. Theranos was founded by a 30-something Elizabeth Holmes, who garnered over $5 billion from investors to launch her company that promised blood from finger sticks vs. whole venous blood draws. This year her company was investigated by the Department of Justice for investor fraud. Today Theranos has little investor value, but Ms. Holmes helped launch the consumer based blood lab model – in which patients can order blood labs from online companies when they want – essentially taking away a physician-ordered medical procedure.
While it may not mean too much for medical fitness professionals today – it should. There are two reasons. Even though Theranos is not the top dog in the blood lab industry now – they have changed the way we think of blood labs in general.
The big picture here, as explained by Stokes in his article, is that whatever the endpoint is for Theranos, consumer based lab testing is here to stay and will be one of the fastest growing areas of healthcare.
Simply put – consumer based blood lab companies allow patients to log onto web sites and essentially become “members” of an online community. Their membership allows them to receive blood labs independent of their physician referral.
Why is this important? For the Medical Fitness Professional – it is the game changer that they have been waiting for. Over the past 25 years they have pushed the terms “post rehab exercise” and “clinical exercise” to allow trainers to move into the health care environment.
While performing duties that may in some cases seem similar to physical therapy (in the eyes of the uneducated observer) they are now able to have a piece of health care that they can use to further their development of the clinical exercise realm.
Blood labs will allow personal trainers, health coaches, health nurses, sports conditioning coaches, and exercise physiologists to refer their clients and athletes to blood lab companies online and directly test the effects of an exercise and sport program on their health.
According to StepOne Health CEO Craig Brandman, MD – over 90% of healthcare decisions are make by the results of blood labs, and in sports medicine – we can only imagine looking at blood labs on an on-going basis to see how our prescribed exercise (or sport) program is doing on blood lab parameters.
Take diabetes for instance – in athletics or health improvement, the basis for medical decision making is in two critical areas – fasting and post blood glucose testing with a home monitor and long term care regarding the glycosylated hemoglobin (A1c). These tests are crucial to seeing how improvements are doing in overall diabetes health. The first test – the home glucose monitor – can be used in any health club and by anyone. The A1c test is a lab test and is usually prescribed by a doctor – until now.
Dr. Brandman and myself have been in communication for some time to bring StepOne Health into the realm of the health and fitness profession. As a former medical researcher – I can’t agree more. With cancer patients, weight management, hormone management, cardiovascular risk patients, and most others, the ability to manage blood labs may be the most important element in showing others in health care the benefits of exercise and sports training at any level.
Sports training programs rely on physical performance markers, injury status, range of motion, and other elements to see the improvement in athletes. Blood testing allows them to not only measure acute markers (blood glucose, lactate, etc.), but to look at markers such as Creatine, Testosterone, and BUN levels and prescribe fitness accordingly.
How will this come to pass? In my conversations with Dr. Brandman – we are working on two fronts. First is to enhance the education of health and wellness professionals as a whole. The Blood Lab Wellness Specialist course was launched in February of 2016, and it allows heath and wellness professionals to have a baseline understanding of the blood lab process. Second – StepOne Health will be creating a referral-based system whereby Medical Fitness Professionals and coaches can directly refer clients to the StepOne Health portal and become part of the referral family. This will include discount rates on blood panels, referral fees for professionals, genomic testing profiles, and online coaching when needed. In my opinion, it is the single most important step in bringing wellness and fitness into today’s health care system as any single faction.
I recently had the opportunity to interview Dr. Brandman about the issues concerning healthcare. In his opinion, health and fitness professionals SHOULD be referring clients to blood work. The more clients know about how their fitness impacts their overall health status, the better. See the interviews with Dr. Brandman on my medhealthfit YouTube Channel here:
Lastly – the profession of medically based exercise is steeped in our tradition of sports medicine. Allowing for blood lab data (under HIPPA guidelines of course) to steer the course of exercise programs makes for formidable outcomes measures and research. It will allow practitioners to absolutely have clear cut outcomes on the programs they are teaching and will only strengthen the association with medical practice groups, hospitals, and health plans, who are looking for the best opportunity to work with providers at the best possible pricing. It is a win for all parties – especially patients, who can see how exercise truly affects their health status.
For more information – log onto www.steponehealth.com and look over the web site.
For more information on the Blood Lab Wellness Specialist, visit medhealthfit.com/health-lab.
Eric Durak is a pioneer in the post rehab movement. He has worked in personal training, medical research, environmental health, and is the author of numerous industry certification courses, such as the Cancer Fit-CARE program / coaching program, Fitness Medicine, Wellness @ Home, The Insurance Reimbursement book for wellness professionals, and recently – the Blood Lab Wellness Specialist. See all of his programs at the medhealthfit.com web site.
A recent issue of the Annals of Internal Medicine tried to put a nail in the coffin of nutritional supplements. “Unregulated, not safe, harmful, and no benefits” shouted the authors of the Letter to the Editor of the journal. Yet another attempt by physicians and the pharmaceutical industry to put a damper on the use and sale of vitamins and minerals.
A recent report in Forbes Magazine by writer Unity Stokes discusses the recent issues concerning the validity of blood tests results from a Silicon Valley lab company called Theranos. While reading about the validity of blood tests may be considered more important for healthcare professionals such as a medical doctor or a nurse, it is time that exercise physiologists as health and fitness professionals take a moment to think about it and what it may mean to their practice.
$750 billion is a lot of money. It is more than the GDP of many countries. And, according to a recent article published on Medical Consultants Network – it is the amount of money wasted each year by our fabulous health care system. Unimaginable as it may seem, the report from the Institute of Medicine found that the amount of money wasted (roughly 30 cents on every medical dollar) is more than the budget of Medicare ($716 billion per year).