An Analysis of the Numbers
Dizziness, vertigo, imbalance, falling and fear of falling are very common complaints in the adult population, and increase with age. Emergency Department (ED) data obtained from the National Ambulatory Care Survey show a 97% increase in annual visits for dizziness from 1995 to 2011, accounting for 3.9 million visits in 2011 at a cost of 4 billion dollars. It is estimated that the ED count may represent a minority (18 to 20%) of patients complaining of dizziness, exponentially increasing the overall costs associated with these complaints (Polensik, 2008).
Causes of Dizziness
Various studies indicate the majority of “dizzy” complaints are the result of vestibular dysfunction. Second most common is migraine. International Headache Society criteria for diagnosing vestibular migraine includes ruling out vestibular dysfunction, so vestibular function testing is helpful in establishing a diagnosis in the vast majority of ”dizziness” complaints.
Costs Associated with Dizziness
It is estimated that Medicare costs related to fall injuries approaches 31 billion dollars annually, and the Centers for Disease Control list “vestibular disorders/poor balance” as the first modifiable risk factor for falling.
Dizziness is one of the most common complaints in the ER, yet current management techniques are expensive, low yield, and leave the majority of patients undiagnosed. Imaging studies often performed in the ER, such as CT, CTA or MRI have diagnostic yields of 1%, 1%, and 12% respectively. Commonly used management strategies, such as the use of meclizine or other sedating medication, conflict with current clinical practice guidelines for BPPV, the most common cause of vertigo.
Despite the low yield, there has been an increase in the use of imaging studies in general, and more specifically for the patient complaining of dizziness. The Medicare database tracks changes in utilization over time. In general, since 2011, there has been a 33% increase in Cranial MRI, a 12% increase and cranial CT scan without contrast, and a 52% increase in cranial CTA. More specific to the dizzy patient in the emergency department, utilization of neuro-imaging (mostly cranial CT scanning and some MRI) increased from being ordered on approximately 10% of patients complaining of dizziness to over 40% over the same time period.
Is there a Direct Connection Between Reimbursement and Utilization?
A fully equipped vestibular lab will identify the source of the complaint approximately 90% of the time. Possibly coincidentally, but more likely a direct result of reimbursement decreases, the utilization of these tests has diminished significantly over the past several years. Over the same period of time reimbursement for these tests has reduced similarly.
According to the Medicare Claims Data, utilization of vestibular testing has decreased 18% to 53% from 2011 to 2015.
2011 2015 change
92541 –Gaze, Spont Nystagmus 160K 132K down 18%
92542 – Positional Nystagmus 175K 112K down 34%
92544 – Oscillating Tracking 163K 99K down 40%
92545 –Optokinetic Tracking 207K 97K down 53%
92546 –Sinusoidal Rotation Chair 186K 89K down 52%
This includes factoring in changes to the bundled code (92540). The reimbursement rate for caloric irrigation has gradually been decreasing since 2010, but when the code language was changed and reimbursement dramatically reduced in 2016, the utilization of this test dropped precipitously. The number of caloric tests billed to Medicare dropped by 40% between 2012 and 2017.
Reimbursement Rates for Vestibular Testing decreased 44% to 68% between 2010 and 2017
|Basic Vestibular Evaluation (92541, 42, 44 and 45)||$185.83||$103.36||down 53%|
|Caloric irrigation x 4||$98.80||$32.30||down 68%|
|Basic VNG exam with 4 caloric irrigations||$284.63||$135.66||down 53%|
|Sinusoidal Rotational Chair||$160-320||$104||down 50-75%|
|(CCI edit in 2007 limited to one unit)|
Inefficient management of patients complaining of dizziness, vertigo or imbalance will generate increased costs as the number of patients with these complaints is large and increasing.
The current system is inefficient as the majority of focus and expense is spent on attempting to rule out stroke, which is rarely the cause of these complaints. The current methods leave most patients undiagnosed and mistreated, while at the same time are not even the most effective method of identifying the very few with serious intra-cranial pathology. The HINTS protocol is far more efficient. Over time, this situation is getting worse, not better. There is a clear opportunity to dramatically lower the cost associated with managing these patients, while at the same time improving care and patient satisfaction.
*featured image courtesy Boys Town, via Youtube