Fraud and abuse in vestibular function testing
Last week we discussed some of the factors that have led to such dramatic and unsustainable reductions in reimbursement for vestibular function tests. These include professional turf battles, federal deficits and Medicare’s reaction to past fraud and abuse. This week we take a closer look at the fraud and abuse issue.
For those of us doing rotational chair testing, the issue of fraud and abuse has created a spiraling effect of incorrect over-utilization of the rotational chair code. Around 2002, manufacturers and distributors heavily promoted a relatively low cost 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. Despite the fact that in 2005, the AMA issued a statement clarifying that the 92546 code should not be used for AHR testing, it seems that this statement is largely unknown or ignored. In fact, in 2007, the primary providers of this code, intended solely for rotational chair, were internal medicine and family practice physicians. Does anyone know of a rotational chair in a family practice setting?
Utilization of this code increased by 1400 percent over a ten year period, mostly based on the fact that these primary care physicians performing AHR had been instructed by equipment sales people that they should bill several units of 92546 for each AHR exam. In 2007, Medicare issued a correct coding initiative limiting billing to one unit per day. This resulted in a 75% reduction in payment for true rotational chair, the most sensitive vestibular test available. Since the rotational chair equipment is quite expensive, this reduction will likely reduce availability of rotational chair testing, and reduce accuracy of vestibular diagnosis.
Another vestibular code that has taken a sizable hit in the last several years is 92547 – Use of vertical electrodes (List separately in addition to code for primary procedure)
This code has been all over the place in the past few years. 92547 is an add-on code, meaning it can’t be billed independently, but must be attached to one of the other vestibular codes. For example, if you did the spontaneous nystagmus test (92541), AND you used electrodes to record the eye movement, you would bill 92541, plus one unit of 92547. You can add one unit of 92547 to each test performed that used electrodes for recording eye movement. In the past, a typical test battery includes one unit of 92541, 92542, 92544, 92545, and four units of 92543, so you could bill 92547 time 8 units.
In 2003, you got more for applying 2 electrodes than you did for the entire rest of the ENG battery. Consider that at 8 units of 92547 (at approximately $45 per unit) you could bill an additional $360 per test battery if you used ENG (as opposed to VNG) recordings. Of course, this triggered much abuse (just because you could doesn’t mean you should), and Medicare’s reaction was to reduce the value so much there was no longer a financial incentive to abuse it. In 2005, Medicare recognized the potential for, and occurrences of, fraud. Since the process of revaluing a code takes time, Medicare’s response was to limit the use of 92547 to just one unit per day. After the code was revalued down to about 5 dollars, 92547 was again allowed to be billed in multiple units along with other electrode based vestibular tests. Keep in mind that because of the new bundled code, four of the individual codes have now been combined into one code. You may only add 92547 one time to each code used, essentially eliminating the billing of vertical electrode use for three of the four codes in the bundle. The end result of the bundling and devaluation is that instead of $180 billable for the four codes, we are now down to about $5.
So, Medicare’s response to obvious incorrect billing and overbilling was to reduce payment. That may well deter those committing fraud, but what about those of us committed to providing comprehensive vestibular evaluation? What about our patients who need the services offered by a specialty balance clinic? I wish I knew the answer to those questions.