Caloric Codes Get Iced

We just got word this week that after a two year process to educate Medicare about proper valuation of the caloric codes, they decided to reduce them further. For a description of the history and process leading up to the new valuation, click here.

During our presentation for the two new codes (one for performing bithermal (4) irrigations, and another for performing monothermal (2) irrigations), there was considerable support from members of the RUC (Relative Value Update Committee). The RUC is a panel of medical specialists responsible for valuing medical procedures, and they represent the position of the American Medical Association. There is an arduous process in presenting and defending proposed values for new codes, so getting the support of the RUC is not an easy task. Historically, when the RUC makes a recommendation to Medicare regarding valuation, Medicare accepts the recommendation.

The proposed codes and values came from a collaborative effort involving Audiology, Otolaryngology and Neurology. A representative panel from these three specialties worked together to write the codes descriptors for each proposed procedure, and a survey was conducted to gather feedback from practicing specialists regarding time, expense and complexity of the proposed code.

The process for the caloric codes took about two years, but in the end, we were actually congratulated by the RUC Chairperson for putting together such a clear and defensible proposal. The RUC agreed with our proposed values, and made the recommendation to Medicare to accept them.

As a sidebar, in a separate meeting with Medicare, we pointed out the dramatic reductions in reimbursement were having the effect of reduced access and increased cost to patients and to the system. Using Medicare data, we pointed out that as reimbursement for vestibular testing began decreasing in 2008, so has utilization of most vestibular testing codes. At the same time, Medicare enrollment has increased substantially.

Here are some related facts: A review of 2012 Medicare utilization data reveals that all five codes involved in the videonystagmography test battery (including those performed as part of 92540) have seen significant decreases in utilization since 2008:

  • 92541 – down 19%
  • 92542 – down 36%
  • 92543 – down 25%
  • 92544 – down 39%
  • 92545 – down 50%

In reality, the number of ER visits for dizziness doubled from 1995 to 2011. Utilization of neuro-imaging for dizziness (mostly cranial CT scanning) increased from being ordered on approximately 10% of dizzy patients to over 40% over the same time period.
Cranial CT has an extremely low diagnostic yield for patients complaining of vertigo or dizziness, and misses emerging brainstem or cerebellar stroke (presumably the reason for ordering the scan) more than 50% of the time.

Estimated costs for ER services alone related to dizziness are estimated at $4 billion per year as of 2011. Is the reduction in utilization related to the reduction in reimbursement? Are there new, more effective and cost effective techniques available to manage these patients? Maybe people just aren’t getting dizzy anymore. Maybe legitimate practitioners unwilling to lower their standard of care just can’t afford to do these tests at these reimbursement rates? There has got to be an explanation!

This information was presented to Medicare representatives, with apparently little impact.

The valuation process is complex and beyond the scope of this article. As a practitioner trying to provide these needed and effective services to patients, the bottom line is the total RVU (Relative Value Unit) that determines the dollar amount paid per procedure. The RVU is mainly comprised of two components, the work value (what the practitioner does), and the practice expense value (factoring in cost of equipment, staff, time, etc). In the case of the new caloric codes, not only did Medicare not accept the RUC recommended work value, they reduced the practice expense values for bithermal caloric irrigation from an RVU of 2.56 in 2009, to .51 in 2016. Somehow, Medicare believes that our expenses have been reduced by 80% over the last 7 years.

Here is Medicare’s rationale for this decision as posted in the MPFS:

“For CY 2016, the CPT Editorial Panel deleted CPT code 92543 (Assessment and

recording of balance system during irrigation of both ears) and created two new CPT codes,

9254A and 9254B, to report caloric vestibular testing for bithermal and monothermal testing

procedures, respectively. The RUC recommended a work RVU of 0.80 for CPT code 9254A and

a work RVU of 0.55 for CPT code 9254B. We believe the recommendations for these services

overstate the work involved in performing these procedures. Due to similarity in service and

time, we believe a direct crosswalk of CPT code 97606 (Negative pressure wound therapy,

surface area greater than 50 square centimeters, per session) to CPT code 9254A is appropriate.

To value CPT code 9254B, we divided the proposed work RVU for 9254A in half since the code

descriptor for this procedure describes the service as having two irrigations as opposed to the

four involved in 9254A. Therefore, for CY 2016, we are proposing a work RVUs of 0.60 to

9254A and 0.30 to 9254B.”

It would be helpful for us to know who the “we” are, and what evidence they have that outweighed the recommendations of the RUC. Health care spending and health care quality are important to everyone, not just audiologists. We ask that Medicare be transparent in their decision process and share the basis for this decision that will undoubtedly impact patient care.

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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.