With national healthcare policy so much in the news in recent months, I thought it might be an appropriate time to take a look a few current issues related to Medicare and private carrier reimbursements that have been vexing my practice and no doubt others as well.

By way of background, I am a neurotologist working with audiologists in a clinic that offers a range of vestibular tests for the diagnosis and treatment of balance and vestibular pathology. In order to generate the highest quality test results and the best possible patient outcomes,

my clinic has invested in an array of diagnostic equipment, including a neuro-otologic test center (NOTC) and its rotational chair. We test about 500 patients a year on the NOTC system.

The variety of tests we perform regularly include vestibular-evoked myogenic potentials, calorics, positionals, computerized dynamic posturography, dynamic visual acuity, gaze stabilization testing, rotary chair testing (sinusoidal harmonic acceleration and step testing), and oculomotor testing.

But here's the problem: the current reimbursement structure is outdated and inconsistently applied.

In recent years, the Centers for Medicare and Medicaid Services (CMS) has stepped up its use of third-party auditors to review reimbursement claims from practitioners. It has also increased use of so-called MUE (medically unlikely edits) software to identify inappropriate use of codes.

One result of that enhanced scrutiny is more denials of legitimate reimbursement claims-often with no little or no explanation.

Additionally, the number of units that will be reimbursed per event likewise has become increasingly random. When our clinic initially queried our local Medicare carrier regarding reimbursement for a potential new vestibular test, we were told that six units would be paid for the test. When the MUEs were implemented, only a single unit of the code was routinely reimbursed with intermittent payment of six units It doesn't take an Ivy League MBA to see how such an uncertain revenue stream makes for a stressed profit and loss statement and all that can flow from there.

Another obstacle with CPT codes that practitioners face is that the codes themselves have not been fully updated to reflect the broader array of vestibular testing available to us.

Outdated codes are used for VEMP testing and rotary chair testing, with no current codes available for tests like subjective visual vertical, visual suppression, unilateral centrifugation, visual vestibular interaction, and several others.

In my case, problems associated with CPT codes have forced our clinic to seek redress before administrative law judges, with the attendant legal fees and unproductive use of time.

I became a doctor to spend my days helping patients and not meeting with lawyers. And I'd prefer to know that when a patient presents with a balance problem and a new test on the NOTC is required, the reimbursement we can anticipate will be predictable and consistent.

But there's a larger issue at stake than my inconvenience or business issues, and that's the problem with steadily improving diagnostic testing and the delays associated with Medicare and third-party payors recognizing and reimbursing for these diagnostic tests.

Staying on the leading edge of any healthcare specialty means ongoing battles for reimbursement. Concern for our patients compels us to battle on their behalf.

We need to initiate and keep a momentum going, and one way to do that is by creating new CPT codes for NOTC-based tests (as is in the works for VNG-based tests) and by refocusing on consistency and predictability in their application.

The bottom line: I never want to be a position of having to tell a balance patient: "No, we can't."

J. Douglas Green Jr, MD, FACS, is the founder of the Jacksonville Hearing & Balance Institute (http://www.jhbi.org) in Jacksonville, FL.