The year 2009 brings a new billing code into the world of dizziness evaluation. At the end of October 2008, the Centers for Medicare and Medicaid Services (CMS) released the final 2009 Medicare Physician Fee Schedule. The new schedule includes the American Medical Association Current Procedural Terminology (CPT) Manual code of "95992 Canalith Repositioning Procedure(s), per day."

Medicare considers the Canalith repositioning procedure (CRP) code as a treatment code, but not one that is payable to audiologists. However, all other third party payers recognize audiologists as providers and may pay them for this code.

Evaluation and treatment of benign paroxysmal positional vertigo (BPPV) is within the scope of practice of trained audiologists--a position supported by the American Academy of Audiology and by the American Speech-Language-Hearing Association. Nearly all state licensing boards specifically list vestibular assessment and rehabilitation as within the audiologist's scope of practice.

Therefore, it is vitally important that properly educated and trained audiologists who perform CRP actually bill for it under the new audiology provider code. This hopefully will lead to CMS becoming aware of our skill level and acknowledging our scope of practice, prompting revision that will allow Medicare to reimburse audiology for this code. Of course, we will need to provide our Medicare patients with the proper revised Advanced Beneficiary Notice (CMS-R-131), since we would expect to be denied payment on a Medicare claim for 95992 CRP.

Our scope of practice is based on being properly trained in identifying which canal is involved in diagnosing BPPV. The identification of the involved ear and specific canal has been done using visual examination of patient eye movements, historically accomplished using the naked eye, Frenzel goggles or infrared video recordings (not tracings) of eye movement. A 2007 study looked at visual identification of BPPV. Both experts in identification of the involved ear, canal and type of BPPV as well as audiologists newly trained in BPPV identification were evaluated. Even experts did not agree in the correct identification of BPPV 41 percent of the time, and freshly trained audiologists missed the mark 59 percent of the time. Test-retest agreement within an evaluator was 81 percent for experts and 64 percent for newly trained audiologists.¹Based on this study, visual inspection of video recordings may not be sufficient in helping clinicians make the correct determination of involved ear, specific canal and BPPV type. The previous "gold standard" of visual examination of eye movement or eye movement video needs re-examination. Electronystagmography (ENG) systems cannot record torsion due to the use of the corneo-retinal potential as the measurement. With new torsional infra-red video nystagmography (VNG) recording systems, the tracings can be used to determine the information needed for diagnosis where it was not previously possible in two-dimensional/channel (horizontal and vertical) VNG systems.

Use of a 3-dimensional (horizontal, vertical and torsional) infra-red VNG system may allow a clinician to make a much more definitive diagnosis. During Dix-Hallpike maneuvers, the clinician must determine if the right or left ear is involved, as well as the anterior or posterior canal. The provoked nystagmus involves a torsional component as well as a vertical component. The tracing can be examined in the torsional channel/dimension to determine the ear involved. If the torsion is right beating (based on patient's right) the involved ear is the right ear. If the torsion is left beating the involved ear is the left ear. Examination of the vertical channel/dimension determines which canal is involved. If the nystagmus is up-beat, the posterior canal is involved. If the nystagmus is down-beat, then the anterior canal is involved. The tracing also can be evaluated for duration of nystagmus to determine canalithiasis (gone in 60 seconds) or cupulolithiasis (lasting longer than 60 seconds).

References
1. Blau, T, Shoup, A. (2007). Reliability of a rating scale used to distinguish direction of eye movement using infrared/video ENG recordings during repositioning maneuvers. International Journal of Audiology, 46(8), 427-432.

Terri E. Ives, ScD, AuD, CCC-A, FAAA, is Clinical Director-Audiology at Neuro Kinetics Inc., Pittsburgh, PA. Contact her at 412-963-6649, tives@neuro-kinetics.com.