Timothy C. Hain, MD
Professor (Emeritus) Physical Therapy/Human Movement
Science, Northwestern University Medical School, Chicago IL, USA.
EMAIL ADDRESS: firstname.lastname@example.org
Page last modified: March 5, 2017
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 unfriendly emails. Nevertheless, we diffidently offer our opinions here. 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 have performed phony vestibular tests, and provided superficially plausible reports, that actually have little or no content.
Another way that unscrupulous people found to manipulate the system was to use the "'vertical electrode" code for ENG testing. This code was meant to be used only one time per ENG, but these people used it multiple instances for the same patient. Because this trick is still used in some parts of the country, a clue that an ENG may be fraudulent is that it is done with electrodes rather than VENG, as for this situation the vertical electrode fraudulent code can be used.
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 ECochG testing. In ENG testing we think that the reason that honest clinicians omit detail is that a proper ENG report is many pages long. In ECochG testing, we think that the reason is that ECochG's are hard to do and there is sometimes a shyness about presenting noisy or questionable traces to outside scrutiny. Nevertheless, it seems to us that without underlying data, there is no proof that the test was performed, as well as no method of ascertaining that the quality was adequete, and thus billing could reasonably be denied.
Here, there seem to be many "holes" in the system - ENG's are being ordered/done by people who are not delivering medical care. The quality of the ENG equipment is sometimes very questionable, and finally there are many loopholes in the billing process.
There are several ways to solve this problem -- our thought is that these measures would be effective:
- 1. ENG's should be only "billable" if a physician with relevant subspecialty training requests one. There should be an indication for the ENG. In other words, ENG's could be ordered by the individuals involved in the present abuse patterns -- including chiropractors, primary care doctors, PTs and "stand alone" audiologists.
- 2. A laboratory certification procedure should be in place (see item 4), and ENG's should not be billable without certification.
- 3. The loopholes in the billing procedures should be closed.
Another method found by unscrupulous groups to "game" the Medicare billing system was to bill repeatedly (on the same day) for "sweeps" of active head movement testing, using commercial active head movement testing systems such as the "Vorteq" and "VAT". While there is some value to these tests, they are not as useful as a "real" rotatory chair and also do not require anywhere near the same investment of space and equipment as the "real system". Another discussion about this method of rotatory chair test fraud can be found here.
- Define a billable rotatory chair test as one that uses a motorized rotatory chair. Increase the reimbursement for this test to properly reflect the very high cost of these devices.
- Define a second code for active head rotation testing, reimbursed at a lower level.
- Limit billing for rotatory chair tests or active head rotation testing to 3 tests per lifetime (most dizzy people need only one/lifetime)
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. In California, entrepreneurs used portable testing systems in vans, that went to nursing homes.
Because of this abuse, Medicare in California restricted payment by forcing the billers to provide the serial numbers for their equipment. We think this is reasonable.
Medicare, unlike many other insurance providers, has authorized payment for computerized dynamic posturography. Some groups, have substituted a "clinical", non-computerized 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). Variant (not necessarily "stripped") posturography platforms are also sold by other vendors such as Micromedical and BalanceBack.
In our view, the full CDP, such as originally invented by Neurocom, Inc, is useful both for quantitation of balance as well as diagnosis of malingering. The stripped down versions have no diagnostic value but are adjuncts to treatment.
Our suggestions are as follows:
We are also unsupportive of diagnostic posturography testing being billed for by stand-alone, Chiropractic, PT or audiology practices (see item 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 for any balance test without expert physician orders (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, not vision or proprioceptive). 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, but we have observed considerable fraud and abuse.
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 ECochG 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. We are also perturbed when we routinely see ENG test reports unaccompanied by any traces (i.e. proof that they were done), and ENG's that leave out important pieces of information from the report (such as the total response).
Our suggestion here -- these tests should only be billable when ordered by an otologic physician.
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 below for additional comments.
Our suggestion here - -better training of audiologists who do vestibular testing, and recertification of audiologists who do vestibular testing every 10 years.
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, ophthalmology, or neurology. These are the specialties that deal with the ears, eyes, sensation, central integration and motor output.
We feel that audiologists are generally not appropriate persons to interpret vestibular " tests. The logic is given above -- audiologists simply are not experts on visual function, sensory proprioception or neurology. Interpretation of so-called "vestibular tests" requires this expertise.
An exception is the ECochG test. The ECochG 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 ECochG 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. In other words, internal medicine and family practice physicians would not be able to bill for these tests.
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 diagnostic procedures like these without physician orders and 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.