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Professor of Neurology, Otolaryngology, and Physical Therapy/Human Movement
Science, Northwestern University Medical School, Chicago IL, USA.
EMAIL ADDRESS: t-hain@northwestern.edu
Page last modified:
June 8, 2008
Recently there has been an upsurge in vestibular testing fraud. This is an inflammatory topic, because it involves billing and assessment of competence. In discussions like this, one inevitably ends up implying that certain groups are incompetent and/or unethical, and this invitably ends up generating some rather unfriendly emails. Nevertheless, we diffidently offer our opinions here (see also the "rants/raves" section on this site. The author (Dr. Hain), is a professor at Northwestern University in Chicago, and does this testing routinely. He competes with some of the groups being discussed here. Commentary sent to the email address above is gladly accepted but it may be added to the content of this page.
A group of persons originally from Russia have discovered that Medicare does not closely scrutinize billing for ENG testing. These people perform phony vestibular tests, and provide superficially plausible reports, that actually have little or no content.
In general, one should suspect fraud when a written report is produced without any underlying data. Common situations where this happens in ENG testing and ECOG testing. In ENG testing we think that the reason is that a proper ENG report is many pages long. In ECOG testing, we think that the reason is that ECOG's are hard to do and there is sometimes a shyness about presenting noisy or questionable traces to public scrutiny.
This problem would go away if supervision was required for these procedures and a laboratory certification procedure was in place (see item 4).
I was recently mailed a solicitation for a "state of the art VNG/ENG system ..." (here). This group can't spell "vestibular", or "minute", and may simply be another example of the people in group 1.
Medicare has recently authorized payment for computerized dynamic posturography. Some groups, have substituted a "clinical" version of posturography, using the "foam and dome". This is not the same thing, and these variants (in our opinion of course) should not be covered by insurance. There are also "stripped down" versions of posturography, some of which are sold by the vendor (Neurocom) that obtained the medicare coverage for the full procedure (computerized dynamic posturography). We do not think that these "stripped down" testing procedures should be covered as diagnostic tests, and should not be billable by audiology practices, but we do think that they are reasonable additions to the physical therapy assessment process and billable as part of that process.
We are also unsupportive of diagnostic posturography testing being billed for by stand-alone, Chiropractic, PT or audiology practices (see item 4 below).
For physical therapy (PT) practices, posturography can be useful for clinical assessment, and we feel that for this instance, the billing should not be for the computerized procedure, but rather for the clinical assessment code. In other words, we feel that posturography could be part of the PT clinical assessment, and also that it could be used to follow progress. In other words, it is our position that standalone physical therapy practices should not be permitted to bill for diagnostic uses of posturography. The reason for this is that physical therapy is an interventional occupation, rather than a diagnostic occupation.
For stand-alone audiology practices, we suggest that they should not be able to bill without expert physician oversight (see below). The problem is that most audiologists do not have the expertise necessary to interpret balance testing, when imbalance is due to a problem other than inner ear disturbances. Balance requires good function of 3 senses (vision, vestibular, proprioceptive), central (brain) integration, and an effective motor output. Audiology training -- emphasizes inner ear function and covers only a small part of this content (vestibular input). We do think that audiologists can do the technical part of posturography testing, but we think that there should be a certification procedure.
We are unsupportive of chiropractic practice billing for posturography testing, as we see only a minor relevance of posturography to spinal manipulation.
Certain testing procedures useful for vestibular testing, such as VEMPs, can be done quickly and are sometimes done by Chiropractic, Physical Therapy or Audiology practices who bill independently, but have no requirement for medical oversight.
The problem here is that the quality of these procedures is extremely inconsistent. For example, we recently saw a neck VEMP done by a local physical therapy practice in Chicago, in which the p1 and n1 peaks were picked at 35 msec. Because the p1 peak occurs between 13 and 18 msec, it is very clear that these people not only had a major technical problem, but were also unaware of the basics of the procedure.
We also routinely see ENG's done by audiology practices which are simply awful in quality, as well as ECOG tests done by audiology practices which are extremely poor. We are especially concerned about audiology practices that perform ENG's with air rather than water, as while this is a convenient method, it often results in a false positive for bilateral vestibular weakness.
A mild but pernicious form of fraud has to do with persons who are not neurologists, suggesting in writing that they can make neurological diagnoses. This most commonly occurs when audiologists, in practice for themselves, diagnose "central vertigo", in patients without a recognizable ear disorder. This problem is caused in part by the ability of audiologists, physical therapists and chiropracters to perform and bill for unsupervised CNS tests (some parts of the ENG are intended to diagnose CNS disorders). See item 6 for additional comments.
In our opinion, vestibular and evoked potential testing should generally be overseen by a physician. Furthermore, the physician should be trained and board certified in a relevant specialty -- otolaryngology, neurology, or neurosurgery.
We feel that audiologists are generally not appropriate persons to interpret these tests. The logic is given above -- audiologists simply are not experts on visual function, proprioception or neurology. Interpretation requires this expertise.
An exception is the ECOG test. The ECOG test is confined to the inner ear in its significance, we think that audiologists should be able to interpret them. We do think that persons who do the ECOG should undergo a certification examination however. For tests such as vestibular testing (ENG and rotatory chair), diagnostic posturography and evoked potential testing including ABR and VEMP tests, that have significance extending far beyond the inner ear, our position is that there should be a billing requirement that a subspecialty physician to interpret them.
Our suggestions for the present --
The optimal situation is to have these tests performed by an audiologist or otology technician, and overseen by an otoneurologist. As this configuration is not generally available, we think it is also reasonable to accept vestibular testing done by technicians, and overseen by a board-certified otolaryngologist or neurologist.
We do not think that stand-alone audiology, chiropractic or physical therapy practices should be permitted to bill for these procedures without expert oversight, because they do not generally have the appropriate expertise, the potential for abuse is high, and because we have personally observed a large number of inappropriate studies.
Our suggestions for the future
We would like to see stricter standards for billing for vestibular testing and a laboratory certification procedure.
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Timothy C. Hain, MD