Technical Requirements for Clinical Exercise Physiologists as Qualified Health Professionals

Abstract

Apply It! 

• Readers will be able to advocate for the field of clinical exercise physiology with an enhanced understanding of the current state of the profession.

• Readers will have a platform to have discussions with other allied health professionals to increase awareness of the role of a clinical exercise physiologist in a health care setting.

In Brief

Despite meeting the required technical standards, clinical exercise physiologists (CEPs) have yet to be identified as qualified health professionals (QHPs). Lack of QHP status for CEPs has resulted in limited coverage of services by the Centers for Medicare & Medicaid Services (CMS), leaving CEPs ineligible to be reimbursed for many of the services they provide. Being acknowledged as a QHP would allow CEPs to better contribute to interprofessional health care teams and potentially become eligible for reimbursement for services provided by CMS and other insurance companies.

INTRODUCTION

Clinical exercise physiologists (CEPs) possess a unique range of skills and knowledge regarding exercise testing, programming, and supervision for individuals with chronic health conditions as a result of their comprehensive education and clinical experience. Clinical exercise physiologists are formally trained in the physiological effects, and benefits, of both acute and chronic exercise in healthy and diseased populations. To date, despite their breadth and depth of knowledge and skill, CEPs have yet to be identified as qualified health professionals (QHPs). A QHP is defined by the American Medical Association as a professional who is “qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service” (¹). Obtaining QHP status requires professions to have several technical requirements including: 1) an accredited education process, 2) an accredited certification, 3) continuing competency requirements, and 4) a professional registry. With many in the health care profession unaware or unfamiliar with who a CEP is or what CEPs are qualified to do, many hospital systems struggle with defining an accurate job description for a CEP and may hire individuals without the needed academic preparation to fill the role of a CEP.

Becoming QHPs will help ensure those practicing as CEPs have established educational and clinical standards for working with individuals who have chronic health conditions.

It is important to correctly identify QHPs in health care settings because it demonstrates competence within a respective field by helping ensure a given individual has had proper education and training to hold his or her professional title. However, the current lack of QHP status for CEPs has resulted in limited coverage of services by the Centers for Medicare & Medicaid Services (CMS), leaving CEP's ineligible for reimbursement for many of the services they provide. Recognition as a QHP would allow CEPs to use their full range of skills and knowledge to contribute to interprofessional health care teams. It would ensure that individuals identifying as CEPs have the necessary education, clinical experience, and nationally accredited professional certification to deliver safe and effective personalized training programs to individuals who may be at high risk for experiencing an adverse event during exercise. Obtaining QHP status for CEPs would increase trust and build positive rapport with other health care providers, improve clarity among job descriptions and expectations, align recognition of CEPs with similarly trained allied health professions, as well as increase opportunities for financial reimbursement for a wider range of services. These efforts will increase the CEP's reach into communities by helping individuals manage their chronic health conditions through exercise and physical activity. The purpose of this statement is to outline the current state of the clinical exercise physiology profession, specific to the technical requirements of QHPs, to increase awareness of the profession and substantiate that CEPs are eligible for QHP status. Table 1 outlines how the field of clinical exercise physiology currently meets the requirements to be identified as QHPs.

TABLE 1 - Technical Requirements for Qualified Health Care Provider Status

Technical Requirements	Clinical Exercise Physiologist Criteria
Accredited education process	By 2027, all CEPs will be required to graduate from a college or university accredited by the CAAHEP.
Accredited certification	CEPs must successfully pass ACSM's Clinical Exercise Physiology certification examination.
Continuing competency requirements	CEPs are required to accumulate 60 continuing education credits every 3 years to remain in good standing with their certification.
Professional registry	CEPs can be identified via the U.S. Registry of Exercise Professionals.

It is important to correctly identify QHPs in health care settings because it demonstrates competence within a respective field and increases accountability of a professional. However, the current lack of QHP status for CEPs has resulted in limited coverage of services by the CMS, leaving CEPs ineligible to bill or be reimbursed for many of the services they are qualified to provide.

BACKGROUND AND HISTORICAL CONTEXT

Clinical exercise physiologists are a relatively new addition to the allied health field in the United States. In the late 1960s, the study of exercise physiology was established as an academic pursuit but was not yet identified as a clinical discipline or profession. Seminal work by Saltin, Hellerstein, Naughton, and Bruce, to name a few, helped establish a definitive link between exercise and health and aided in the development of outpatient cardiac rehabilitation programs (²). Initially, cardiac rehabilitation programs were managed by registered nurses and graduates of physical education programs and often held at the local YMCA gymnasium. Eventually, these programs experienced exponential growth and resulted in the American College of Sports Medicine (ACSM) developing a clinical exercise specialist certification (today's Certified Clinical Exercise Physiologist) to staff these exercise programs safely (³). Designed to identify individuals with the knowledge, skills, and abilities to work with a clinical population in cardiopulmonary rehabilitation or similar settings. Clinical exercise physiologists certified through ACSM are professionals who are tasked with providing primary and secondary prevention strategies designed to improve, maintain, or attenuate declines in fitness and health in a variety of clinical populations (⁴). Opportunities for CEPs have grown, and in addition to participating in formal rehabilitation programs, CEPs are now employed across fitness and health care settings, including cardiovascular stress testing, corporate fitness/wellbeing, and medical fitness centers (⁵). In these settings, CEPs work with individuals who present with chronic diseases including but not limited to cardiovascular, pulmonary, metabolic, orthopedic/musculoskeletal, neuromuscular, neoplastic, immunological and hematological disorders, and associated comorbidities.

WORK ENVIRONMENT

Despite training in the acute and chronic responses to exercise among apparently healthy individuals and those with a variety of chronic health conditions, most CEPs in the United States work predominately with patients who have cardiovascular disease (CVD) (⁵). Specifically, CEPs primarily work in cardiac rehabilitation and exercise stress testing laboratories (⁵). This emphasis on CVD-related programs, despite training in a broad range of chronic conditions, is likely a result of two main factors. First, CVD, is a major public health challenge in the United States and worldwide, and is the leading cause of death in men and women (⁶). Nearly 50% of adults have some form of CVD, which includes coronary heart disease, heart failure, stroke, and hypertension (⁷). Exercise stress testing and cardiac rehabilitation are standards of care in the diagnosis and secondary prevention of heart disease, respectively; thus, there are many employment opportunities in these areas.

The second factor for the CVD focus is health insurance coverage for services that could be provided by CEPs. In the United States, CMS defines coverage guidelines for health care services that are provided to beneficiaries of Medicare and Medicaid. Private health insurance companies develop their own guidelines, which are often based on those defined by CMS. As of 2021, there are a limited number of services that CMS covers that fall within the typical training of a CEP. These include cardiac rehabilitation, pulmonary rehabilitation, supervised exercise training for patients with peripheral artery disease, and exercise stress testing. These services are billed as a procedure/program and not an office visit to an individual clinician. The CMS does not define the staff who can provide these services, only that there is a supervising physician of record (⁸). As a result, these services might be staffed entirely by CEPs or other health care providers, or a combination thereof (^9,10). In addition to the services listed earlier, CMS covers diabetes self-management training that can be delivered by a CEP after he or she becomes a Certified Diabetes Care and Education Specialist (^11,12).

Despite the limited services that are covered by health insurance companies that could be delivered by a CEP, many institutions have been able to offer CEP-led exercise training programs for patients with chronic disease beyond those previously listed. Common among these are programs for patients enrolled in clinical weight loss programs, before or after bariatric surgery, or diagnosed with cancer. Various models have been used to cover the cost to operate these programs. These include patient self-pay, research grants, grants funded by philanthropic efforts, and individual arrangements between medical providers and private health insurance providers.

MINIMAL COMPETENCIES

Minimal competencies for CEPs are assessed by a national certification examination such as ACSM's Certified Clinical Exercise Physiologist examination (ACSM-CEP). Before sitting for the ACSM-CEP, a candidate must either 1) earn a master's degree in Clinical Exercise Physiology (or related field) and obtain more than 600 hours of hands-on clinical experience or 2) earn a bachelor's degree in Exercise Science (or related field) and obtain more than 1,200 hours of clinical hands-on experience (¹³). It is recommended that students take 21 semester hours of coursework related to exercise physiology, strength and conditioning, applied kinesiology or biomechanics, anatomy and physiology, exercise testing and prescription, and health risk appraisal. In addition, CEPs need to be competent in areas including electrocardiography administration and interpretation and pharmacology. Individuals who wish to sit for this national certification examination must submit an online application, which includes a clinical experience documentation form, official university transcripts, a summary of required courses from their academic program with university catalog descriptions, and proof of basic life support (BLS)/cardiopulmonary resuscitation (CPR) for the professional rescuer certification (Table 2). A more detailed explanation of these domains and the examination in general are outlined below.

TABLE 2 - Domains on the American College of Sports Medicine's Clinical Exercise Physiologist Certification Examination

Domain Number	Content Topics (% of Examination Content)
Domain I	Patient Assessment (20%)
Domain II	Exercise Testing (19%)
Domain III	Exercise Prescription (23%)
Domain IV	Exercise Training and Leadership (23%)
Domain V	Education and Behavior Change (10%)
Domain VI	Legal and Professional Responsibilities (5%)

NATIONAL CERTIFICATION PROCESS

ACSM conducts a job task analysis for the CEP certification approximately every 5 years to ensure that the performance domains and certification examination content reflect the current knowledge, skills, and abilities (KSAs) required to work safely and effectively as a CEP (¹⁴). The job task analysis process includes: 1) a focus group meeting where a subject matter expert (SME) panel reviews, revises, and updates (as needed) the expected knowledge and skills of practicing professionals, 2) a survey of actively practicing CEPs allowing for review of the revised content, and 3) a follow-up meeting of the SME panel to review the results of the survey. The process ensures that the ACSM CEP certification examination is a valid and reliable tool to evaluate candidates' KSAs related to the profession, and passing the examination reflects that they are minimally competent to safely enter the work force.

Currently, the performance domains for ACSM-CEP examination include: 1) patient assessment (20% of examination content), 2) exercise testing (19% of examination content), 3) exercise prescription (23% of examination content), 4) exercise training and leadership (23% of examination content), 5) education and behavior change (10% of examination content), and 6) legal and professional responsibilities (5% of examination content) (¹⁵). In each domain, the ACSM CEP certification examination requires candidates to answer questions with varying levels of cognitive challenge (¹⁵). Recall questions assess a candidate's ability to remember basic facts, information, and/or steps in a process. Application questions assess candidates' ability to comprehend and implement processes, interpret simple results, and summarize information. Synthesis questions require candidates to make judgments on new information based on given criteria, critique processes, and make recommendations. Because recall, application, and synthesis are skills CEPs use in professional settings as they work with clients/patients, assessing candidates in these areas demonstrates certified CEPs are qualified to enter the work force.

To pass the ACSM-CEP certification, candidates must earn a scaled score of 550. This standardized score is derived via the modified Angoff procedure, which is a standard setting process (¹⁵). The modified Angoff procedure used by ACSM is considered best practice, and a process like this is used by most certification examination programs in engineering, medicine, nursing, and for many other U.S.-based licensing and certifying examinations. Current pass rates for all ACSM certification examinations are always available on ACSM's web site. In 2019 and 2020, the pass rate for the ACSM-CEP was 66% and 69%, respectively. In addition, a CEP must renew their certification every 3 years (¹⁶). To renew their certification, CEPs are required to pay a recertification fee, maintain a current BLS/CPR certification, and accumulate 60 continuing education credits from approved educational providers. Continuing education requirements for certification renewal ensure that licensed/certified professionals maintain and enhance their knowledge, skills, and abilities and remain current with industry standards and professional practice.

EDUCATION STANDARDS

Recently, ACSM recognized that the lack of universal programmatic accreditation requirements for ACSM-CEP certification was detrimental to efforts for establishing CEPs as QHPs. Therefore, although academic programs are not required to be programmatically accredited today, effective April 15, 2027, all ACSM-CEP candidates will be required to earn a degree from an academic program that is accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP) (¹⁷). In 2004, CAAHEP established the Committee on Accreditation for the Exercise Sciences (CoAES) (¹⁸) and accredited its first undergraduate programs in 2007. Programmatic accreditation in Applied Exercise Physiology and Clinical Exercise Physiology were soon introduced. Standards and Guidelines for Programmatic Accreditation in Exercise Science (undergraduate programs) (¹⁷) and Exercise Physiology (graduate programs) (¹⁹) provide the framework for CAAHEP outcomes-based accreditation and are reviewed annually and published by CoAES and CAAHEP. Unique among the recognized national accreditors, CAAHEP and the CoAES create measurable outcomes as opposed to process-based accreditations, which are very prescriptive, and reflect that. The CAAHEP accreditation is focused on what successful graduates do once they graduate rather than how they got there. Process-based accreditation prescribes the type and number of courses required for students, whereas outcomes-based accreditation focuses on outcomes, such as the number of students who take and pass a national certification examination.

NATIONAL REGISTRY

As previously mentioned, a national registry is a technical requirement to meet QHP standards. National registries provide the public information regarding a professional's qualifications and allows clients, employers, state agencies, and other professionals to confirm that an individual is in good standing with certifications or licensure requirements. Currently, CEPs can be identified via the U.S. Registry of Exercise Professionals (²⁰). This not-for-profit organization currently has more than 150,000 active credentials and aims to “secure recognition of registered exercise professionals for their distinct roles in medical, health, fitness, and sports performance fields” (²⁰).

NATIONAL PROVIDER IDENTIFIER

Given the limited available services that are currently covered by CMS, a pivotal goal for the profession of clinical exercise physiology is for CEPs to be eligible to bill, and be reimbursed for, providing their services (²¹). A critical step to achieve these goals includes increasing the number CEPs who have registered for an individual national provider identifier (NPI). National provider identifiers are unique 10-digit identification numbers used by health care organizations and health insurance companies to verify information about health care service providers. The Health Insurance Portability and Accountability Act (HIPAA) requires that health care providers who use electronically transmitted health information during HIPAA-applicable transactions have an NPI (²²). Although some CEPs may work within a hospital system that has a group NPI associated with their institution (²²), it is still important for CEPs to register for an individual NPI. Currently, there are relatively few CEPs who have obtained individual NPIs. It is vital to the profession that CEPs take the initiative to register for their individual NPI because this will improve the visibility of CEPs as practicing health care providers and support the growth of the profession by providing a quantifiable number of practicing CEPs. To gain support for legislative initiatives for insurance reimbursement, increasing the number of CEPs with an assigned individual NPI is essential (^23,24).

SUMMARY

The profession of clinical exercise physiology has made great progress over the past 70 years, but CEPs have yet to be identified as QHPs. As outlined earlier, the profession has put in place the necessary requirements to meet the technical standards required to obtain QHP status. Gaining recognition as QHPs will increase the visibility of CEPs and confirm that practicing CEPs are valued members of health care teams. In addition, QHP recognition for CEPs would add another layer of protection for members of the public, ensuring that members of high-risk populations work only with certified professionals who have the necessary qualifications in education and clinical experience.

Qualified health professional status may protect the public by enforcing standards and help high-risk populations avoid working with professionals who do not meet the necessary qualifications in education and clinical experience.

To learn more about this profession and related initiatives, see the following resources:

• American College of Sports Medicine: https://www.acsm.org
• Advocacy Resource: https://www.acsm.org/about/advocacy
• Clinical Exercise Physiology Association: https://www.acsm-cepa.org
• U.S. Registry of Exercise Professionals: http://www.usreps.org/Pages/default.aspx
• Commission on Accreditation of Allied Health Education Programs: https://www.caahep.org
• Committee on Accreditation for the Exercise Sciences: https://www.coaes.org

BRIDGING THE GAP

Clinical exercise physiologists are well positioned to become QHPs.

Becoming identified as a qualified health provider will help CEPs be better understood by other health care providers.

Programmatic accreditation is a critical step toward CEPs achieving QHP status.