The road to hell is paved with good intentions. That is a gruff, but probably accurate assessment of how the field of vestibular management was severely injured by the introduction of a low cost, easy to use, quick, inexpensive tool to measure the Vestibular-Ocular Reflex (VOR) for rapid head movements. Rotational Chair testing had been, and still is, the standard for accurately measuring VOR response to slow to moderate speed head movement. This newer test, known as Active Head Rotation (AHR) was, and still is, a great technique to assess the VOR for rapid head movements where visual stability would be diminished in a patient with a VOR deficit.
So far, so good. We had some brilliant people working to create helpful clinical assessment equipment and protocols. My sentiments towards them hold nothing but admiration. Unfortunately, some less than brilliant people got involved. I think the words “greedy, short-sighted, irresponsible, scammers” and so on would be more appropriate. I wrote an article for Audiology Today a few years ago on this subject. Here is an excerpt, but if you have a minute, click to the link and read the article.
“Two things happened around 2002: reimbursement increased to about $78 per unit, and manufacturers and distributors heavily promoted an Active Head Rotation (AHR) test that technically fell under the descriptor for 92546 (sinusoidal vertical axis rotation), although this was never the intended use for this code. Manufacturers guided their customers to perform 3 horizontal sweeps, and 3 vertical sweeps, to reduce artifact and increase test reliability. This was clinical advice, and should not have been confused for billing advice. Some distributors offered billing advice and instructed their customers to bill one unit for each sweep, for a total of six units. In 2001, this resulted in a payment of about $150. After 2002, this same billing pattern resulted in a payment of about $460. This windfall was recognized by some equipment distributors and practitioners, and utilization increased dramatically over the next few years. Balance Clinic Packages were being promoted to physician groups that had not previously shown any interest in vestibular testing.
Consequently, businesses started popping up selling this equipment with some interesting sales approaches. Such companies were apparently quite persuasive in getting primary care physicians to purchase this equipment because the frequency of billing for the rotation chair code rose by 1400% between 2001 and 2007. In 2005 , in response to this billing bonanza, the American Medical Association issued a statement making it perfectly clear that the rotational chair code (92546) should not be used for this new active head rotation system.
My issue is not with the manufacturers of AHR equipment. I own two of these units and use them on appropriate patients. However, I do not bill Medicare as if I were doing an actual rotational chair test, which we also do regularly. I don’t really even have much of an issue with the primary care providers who are using this equipment and billing it incorrectly. They are trusting these salespeople, and making some effort to quantify the patient’s complaint of dizziness. I am an advocate of primary care physicians becoming more involved in screening for vestibular disorders and treating straightforward conditions such as posterior canal BPPV. I do fear that they may be a very unhappy group when the RAC rolls around to audit their billing.
I do have a BIG issue with salespeople and distributors who mislead their customers for a quick sale, give them incorrect billing/coding advice as part of the sales pitch, and, frankly, try to tell them that evaluating dizziness is easy. After specializing in vestibular disorders for over twenty years, I can tell you it is rewarding, challenging, interesting, but it ain’t easy. And you can’t learn it in a two-day onsite training, with 10 hours of that time devoted to billing and coding. I think that being honest, providing your potential customers with accurate information, not claiming other people’s work as your own, and full disclosure about your company and its principals should be a minimum expectation. Don’t you?
Come back next week for an example of a company that does not seem to worry about these standards.
Thanks for the article. I started at a new ENT practice this past year that wanted to develop a true vestibular/balance lab. I had to work hard to convince one of the ENTs that our AHR was a valid test, but not a “poor man’s rotary chair”. Thankfully he listened to reason (especially when I explained the billing issues of improperly using 92546 for AHR) and we’ll soon have both AHR & rotary chair. Your article makes me feel validated.