Connecting the Dots: Part I

dotsOver the past few years on this blog I have discussed on several occasions the reductions in reimbursement for vestibular testing. I have also made the statement that clinical practice is often driven by reimbursement, and that changes in reimbursement eventually affect the way people practice. While this is a frightening yet logical conclusion, it is a difficult statement to prove. I have gathered up as much publicly available information as I could find to allow the reader (that’s you) to connect the dots and draw your own conclusion.

We have all heard much about the “Graying of America” and the massive number of people that are reaching Medicare age. We have seen published reports out of Johns Hopkins estimating that approximately one out of three elderly people have signs of possible vestibular deficit. We have read scary reports about the frequency and consequences of falls in the elderly. So, logic would lead one to conclude that there should be a corresponding increase in the number of people undergoing vestibular evaluation. Au contraire, mon frère.

In 2008, several of the codes used in vestibular testing were targeted by Medicare for various reasons (that’s a topic for another day), and reimbursement started decreasing, and not just a little. Reimbursement has gradually decreased to levels below the actual cost of delivering the service, so many practitioners either rely on other sources of income to keep their vestibular clinic open, or they just quit offering the service. If that’s true, there should be documentation of decreased utilization of the vestibular exam codes. According the RUC database (which tracks these types of things), the amount of vestibular testing done in that booming Medicare population has actually decreased, and not just a little.

Since 2010, the Videonystagmography battery (VNG), excluding 92543, is most often billed as part of the bundled code, Basic Vestibular Evaluation, CPT code 92540. A review of 2012 utilization data reveals that all five components of the VNG battery (including those performed as part of 92540) have seen significant decreases in utilization since 2008:

92541 (Gaze, Spontaneous Nystagmus test) – down 19%
92542 (Positional test) – down 36%
92543 (Caloric irrigation) – down 25%
92544 (Optokinetic Tracking test) – down 39%
92545 (Osclillating Tracking test) – down 50%
(source: AMA RUC database)

These are pretty dramatic reductions in utilization for a common complaint in a growing population. This leads to the questions:

Are there just fewer patients complaining of dizziness?
If they are not getting vestibular testing and treatment, what is being done to address their complaints?
Are there newer, more effective methods to diagnose these patients that are replacing vestibular testing?

Come back next week and I will do my best to answer these questions and give you the data you need to connect the dots.

Photo courtesy of

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.