Think you want a code for vHIT? Think again.
Currently there is no code for vHIT, but I frequently hear from practicing Audiologists that there should be. Most of the procedures we use for the diagnostic evaluation of the dizzy patient have been assigned Current Procedural Terminology (CPT) codes. These codes describe the service, and each code is assigned a value for payment. This whole process is completed under the control of the American Medical Association (AMA), but Medicare (CMS) can disagree with AMA values, and assign any value they choose.
For a procedure to obtain a code, it must be commonly performed and have some evidence of efficacy, so new procedures can sometimes take years before they complete this process and are reimbursed by Medicare. Procedures that do not have codes can still be performed, and they can be billed directly to the patient as a non-covered service. Because no value has been assigned, the patient and practitioner can agree on the value.
Once a procedure receives a code and a value, the practitioner’s charge is limited by that value whether they participate with Medicare or not. Some physicians choose to “opt out” and not “accept assignment” allowing them to charge up to 115% of the assigned value. Audiologists, because of our placement in the Diagnostic category, do not have the option of opting out. For this same reason, we cannot be paid by Medicare for any treatment such as Canalith Repositioning.
The bottom line is that once Medicare assigns a value that is that. As an Audiologist, you cannot charge a Medicare patient any more than the assigned value for the procedure, and there is no way around that.
So what happens when a procedure is valued lower than the cost of providing the service?
There are really only two choices: 1) you can stop doing the procedure, or 2) you can continue to do it at a loss and count on other profitable procedures or activities to keep the practice solvent. This second model is what keeps most audiology facilities afloat. Since the hearing testing codes were significantly reduced in 2007, it has become crucial that an audiology practice sells enough hearing aids (priced at market value) to keep the practice profitable.
Vestibular Evaluation and Reimbursement
In the practice of vestibular management, we only have to look as far as the code for caloric irrigation to see how this plays out. The details behind the current value of the caloric codes is a long and incredible journey in itself starting in 2010, but for the sake of this post you need to know only a couple of things.
An unnamed CMS panel chose to ignore the values produced through three years of process, survey, consensus, deliberation and voting, and decided to reduce the work value by 45% from the recommended value. Not surprisingly, many practitioners have chosen the option to stop (or at least reduce) performing caloric testing.
Since reimbursement has decreased overall by 58% since 2010, the number of caloric tests performed has reduced by 40%.
This is not a fluke. When the rest of the VNG battery was revalued as a bundled code, the value dropped by 45%. When the basic audiometric evaluation code was revalued in 2007, it was reduced by 23%. When Otoacoustic Emissions were revalued in 2012, they were reduced by 25 to 35%. This is now the norm, not the exception.
Medicare controls payment. They should not control practice.
The technology used to diagnose dizziness has changed over the years. There are currently no CPT codes for VEMP or vHIT testing. Both of these procedures benefit from widespread use and proven efficacy. While proceedings surrounding new code development are confidential, due to the recent survey distributed, it is no secret that a code for VEMP testing is on its’ way. Personally, I feel that it was a mistake to submit a code for VEMP. Given the recent history of code valuations for vestibular testing, the chances of adequate reimbursement are slim. Although the procedure itself is performed fairly quickly, VEMP testing requires time consuming meticulous preparation, expensive equipment and valuable space. I ask you to do a quick calculation in your head. Based on the time and equipment costs involved, what do you think is a fair value? Let’s see how close you come when the AMA and CMS valuation process is completed.
There is no mandate that requires all procedures be assigned a CPT code. It is required that a procedure go through the process and receive a code and assigned value if you want Medicare to pay for it. Given the history, I think it is best if new procedures are kept out this process, therefore not giving Medicare the chance to value it below the cost to provide the service.
OK, so what about access?
I have heard people say that we need codes for VEMP and vHIT so that patients have access to these tests. They do have access. Currently, a practitioner is free to offer these services at a fee set by the practice, and the patient can choose to have the procedure or not. What happens when the value is too low? The procedure becomes less available and access is limited (see caloric code above).
The evidence shows that by performing vHIT, a significant number of patients will not require caloric testing. vHIT is a fast and effective test with important clinical utility, and is far easier on the patient than past test techniques. The equipment cost is significant, so reimbursement levels must be adequate to promote use of this technology.
If you believe that CMS will reimburse vHIT at a level to encourage more practitioners to invest in this equipment and increase patient access, then a CPT code would be attractive. Do you believe that?
*featured image courtesy Micromedical Technologies