How long does a complete battery of balance testing usually last?
A complete battery of testing for balance disorders usually last approximately 1-1/12 hours per patient. Time is dependent upon patient compliance, patient condition presented at the time of testing and the environment in which testing occurs.

Are all patients that fail the balance protocol candidates for testing?
Most of the time the answer is yes. However, there are times in which a patient is not conducive for testing based on issues related to their physical health and condition. These will be covered with you prior to scheduling to prevent this from occurring.

Who should be balance disorder tested?
• Anyone with a history of falling
• Anyone with episodes of dizziness
• Anyone expressing a fear of falling due to poor balance
• Anyone with ringing in the ears
• Anyone 50 years of age or older who has hearing loss requiring a hearing device
• This screening will lead your treating Provider to order appropriate diagnostic testing
 

What are the facts concerning balance disorders?
• 70 percent of patients with symptoms of dizziness are seen by primary care physicians, however only 50 percent are accurately diagnosed
• Over 90 million Americans age 17 and older have experienced a balance problem
• 20 to 40 percent of Medicare-age adults who live at home fall each year
• Half of accidental deaths in the Medicare-age population are fall related
• The fear and results of falling are the primary cause for nursing home admissions
• Balance disorders play a major role in hip fractures in the Medicare-age population
• A significant majority of these patients who underwent total hip replacement suffered a sudden onset of dizziness and fell resulting in a fracture
• 25 percent of all Medicare-age population who sustain a hip fracture will die within one year
• Hospital admissions for hip fractures are projected to grow dramatically as our population ages



Frequently Asked Questions: Hearing Loss

What causes hearing loss?
Lots of factors contribute to hearing loss. Age, genetics, and congenital disorders can cause a reduction in hearing. Physical causes include head trauma, earwax blockage, ear infections, and tumors in the ear. Some diseases can cause hearing loss as well; these include Meneire’s Disease and otosclerosis. Very loud noises can also cause rapid or gradual hearing loss.

How can I tell if I’m experiencing hearing loss?
People who suffer from early hearing loss frequently ask others to repeat themselves, or to stop mumbling their words. They sometimes miss crucial parts of conversations. They might also have difficulty making out dialogue in movies or on television. Common sounds, such as doorbells, might fail to alert them. If you have any of these symptoms, tell your doctor.

Can exposure to loud noises affect my hearing?
Yes. In general, any noise over 105 decibels in volume will cause damage to your ears. This includes gunshots, jets taking off, and rock concerts. Prolonged exposure to sounds of 90 decibels can also cause hearing loss. Always use ear earplugs or other protection when you know you’ll be exposed to loud noises.

I experience a ringing in my ears. Is this related to hearing loss?
It could be. Many people hear a ringing in their ears (known as tinnitus) following a loud noise, such as a gunshot. Others experience the ringing all the time. It might be a reaction to trauma, including overly loud noises, or it could be a sign of something more serious. Tinnitus sometimes comes with aging. Your doctor will be the best judge of the severity of your condition.

What are some solutions for dealing with hearing loss?
If your hearing loss is caused by infection or disease, you’ll need treatment to clear up those underlying conditions. Hearing aids are a popular choice for many patients, but these devices are typically expensive and aren’t covered by most insurance companies. Cochlear implants are an option for patients with severe hearing loss. They directly stimulate the auditory nerve, bypassing the ear altogether.

Every case of hearing loss is different, so be sure to discuss your situation with your doctor.


Frequently Asked Questions: Computerized Balance Evaluation
 

How long does a balance evaluation usually take?
The balance evaluation is designed to take the place of the scales in your office so that it does not require special space. The test usually last a matter of seconds with eyes open and closed for a total of only a minute or so. This will be covered with you in detail on your balance evaluation day.
 

Does the evaluation require any special training?
No. The balance evaluator is very simple to use and requires no special training.
 

What exactly is the balance evaluation?
It is a device that measures the sway factor of a person. The findings are compared to the normative data for a person that same height, weight and age to deliver a positive or negative test result based on this comparison. The information is stored in the computers database for future reference. Our clinic is very busy and we don’t have much time to implement a new procedure.

Will this take much time from our normal office flow?
Absolutely not. Not only does the test itself not require much time, but further testing and treatment is generally done by our technician(s) in your office on a specified day and doesn’t require any of your time. Our system is designed to fit within your normal office flow with very little change being required.
 

How do we evaluate and schedule patients?
You will be instructed on how to use the balance evaluator before its implementation. As stated before we recommend that you replace your scales with the balance evaluator and screen all of your patients for potential balance disorders. It is obvious that those that have fallen or have dizziness, vertigo, etc. need to be evaluated but it is equally important to recognize a balance disorder in a patient before it becomes evident that he or she suffers from a fall. After a fall has occurred it costs the health care system thousands of dollars not to mention potential lives. This is what prevention is all about. Although you have something to offer those that have fallen or have a fear of falling you also have much to offer those that screen positive yet have not shown symptoms associated with falling as of yet. The gold standard of protocol is established when we discover a potential problem before it manifests and prevent it from occurring. Use the balance evaluator wisely and screen each of your patients as they enter your office for health care needs regardless of their presenting symptoms. Patients with a positive evaluation or with symptoms may be scheduled for further testing or orthotic casting, treatment, etc. This is prescribed by the doctor based on findings and medical necessity, and is ordered via the Sure Steps RX.

Frequently Asked Questions: Vertigon Diagnostic Services

Who performs the Balance Disorder testing?
A qualified technologist performs all of the testing. As a Healthcare Provider, your license allows our technologists to perform these studies within the confines of your practice. The test report is read, interpreted and signed by one of our board certified Neurologists.

Do I have to be in the room during testing?
No! A mandate issued by the AMA in October, 2002, stated that for “General Supervision” the Provider does not need to be in the room during testing and that they do not even need to be in the clinic at the time of testing. The testing must be performed in space where the Provider routinely furnishes services according to the Provider’s license outside of the specific testing cited here.

What are my (or my office) responsibilities?
You will determine which patients need testing. Referrals for these patients will be sent to our office via FAX or through our website. THAT’S IT!  Our office staff will do all of the administrative tasks including (but not limited to) obtaining pre-authorizations where required as well as calling for verification of benefits. Our bilingual (English and Spanish) staff then contacts the patient to let them know that they have been approved for testing and we schedule them for testing according to the available times and dates for testing determined by your office. Our staff is in constant communication with the patient and your office staff to assure that your patient is not
inconvenienced and that they receive the finest service possible.
 

What do we need to send to Vertigon with the patient referral?
Two things in particular assist us to quickly get the pre-authorizations and verification of benefits completed:

1. A clear fax copy of the patient’s current insurance card (when applicable).
We are in-network with over 500 private insurance plans, all workers
compensation plans and Medicare.

2. In cases where the patient is covered by an HMO, your office must provide a
referral number from the insurance company prior to sending us the referral for
testing. Our staff is always available to assist you with these tasks.
 

Is an agreement required between the Provider and Vertigon?
Yes. An agreement is required as per the new guidelines issued in October, 2002. This agreement includes a fee schedule that defines the amounts to be charged to Vertigon for the use of space in your office as well as for your time as the overseeing Provider. It also assures that payments will be received as specified in the Federal requirements; specifically “not as a percentage of reimbursement or based on reimbursements of any kind, not on a per-patient basis, and not related to an actual reimbursement of any kind (you get paid even if we do not). This agreement DOES NOT require that you send us all or any of your Electrodiagnostic testing. You may send your patients anywhere you want. We believe that we will earn your long-term business by providing the finest patient care possible, combined with excellent service to you and your staff.
 

How much will the Sure Steps Vertigon service cost me?
NOTHING! You will incur no out of pocket costs to utilize this service. OBS pays for all costs associated with the testing.
 

How is all of this legal?
In October, 2002, many new health care related laws were passed and ancillary services were addressed. It was determined that in order to justify any payment from an ancillary service (OBS) to a referring physician (you), we are required to use “fair market value” guidelines. In short, we
pay for those things that you provide to us in order for Vertigon to perform mobile Balance Disorder testing in your office.

We pay for:
a. Office space
b. Telephone / fax
c. The “general supervision” fee
 

How long does it take to get my patient tested and get the report back?
We average between 7 to 10 days from the date that a referral is received in our office to the time that the patient is tested.

Several things can impact this timing:

a. Incomplete or illegible information on the referral form which necessitates calling the
physician’s office or the patient.

b. Inability to make contact with the patient to schedule the test (incorrect telephone
numbers, etc.)

c. Patient is unwilling to schedule the test until they have met their deductible (we offer
Master Card/Visa/Discover as a convenience to the patient)

d. Patient is apprehensive about having the test done.
Once the test is completed, we guarantee that the report will be faxed to your office within 96
hours. If you desire, an original report can be mailed to you.
 

When do I receive payment for the testing fees?
After you sign the agreement for services and we begin testing your referred patients, our technologists will log their time in and out for each test that they complete in your office. These times are reported to our office each day and are entered into our computer system. The fees due to you for the tests conducted during the month are calculated at the end of the month and are paid to you according to the contract.
 

Why should I use Vertigon for Balance Disorder testing?
The quality and accuracy of our Balance Disorder testing is second to none. Our technologists have been carefully selected and thoroughly trained in state-of-the-art testing techniques. If you have had Balance Disorder testing done at other facilities, it may have taken weeks to get your test completed and your report issued plus your patient must travel to that remote office to have the testing done. We can complete your tests in 7–10 days (sometimes sooner) and will have your report back to you within 96 hours from the test date. You will incur no additional out-of–pocket costs. We handle all of the pre-authorization work, verification of benefits, patient scheduling, billing and reporting while your staff concentrates on running your office. Finally, the patient benefits most by having testing performed in a familiar environment. By the way, Vertigon reimburses you for time and space utilization for all testing performed in your office.

VESTIBULAR TESTING: WHAT IS IT GOOD FOR?

Why get vestibular tests?
1. Vestibular tests are tests of function. Their purpose is to determine if there is something wrong with the vestibular portion of the inner ear. If dizziness is not caused by the inner ear, it might be caused by disorders of the brain, by medical disorders such as low blood pressure, or by psychological problems such as anxiety. Recent studies have suggested that vestibular tests are more accurate than clinical examination in identifying inner ear disorders (Gordon et al, 1996). Hearing pathway tests (audiometry, ABR, ECOG) can also be used for the same purpose, and are frequently combined with vestibular tests. In cost-effectiveness analysis for evaluation for vertigo it was concluded that hearing testing followed by either posturography or ENG (electronystagmography) was the most effective method (Stewart et al, 1999).

2. To detect central disorders. Recent studies have suggested that internuclear ophthalmoplegia, a central eye movement disorder, is missed by 71% of physicians unaided by quantitative oculomotor testing (Frohman et al, 2003).

3. To decide if more expensive tests like MRI (Magnetic Resonance Imaging) are needed. Vestibular testing is more accurate than clinical symptoms in predicting whether neuroimaging tests will be abnormal.(Levy and Arts, 1996)

4. To document objectively vestibular conditions such as BPPV and Perilymph fistula, which commonly occur after head injury, vestibular neuritis, and Gentamicin ototoxicity, which commonly is a side effect of medication.

Video Electronystagmography Testing for Adults

Why do I need a VENG test?
• Vestibular tests are tests of function. Their purpose is to determine if there is
something wrong with the vestibular portion of the inner ear. If dizziness is not
caused by the inner ear, it might be caused by disorders of the brain, by medical
disorders such as low blood pressure, or by psychological problems such as anxiety.
Recent studies have suggested that vestibular tests are more accurate than clinical
examination in identifying inner ear disorders (Gordon et al, 1996). Hearing pathway
tests (audiometry, ABR, ECOG) can also be used for the same purpose, and are
frequently combined with vestibular tests. In cost-effectiveness analysis for
evaluation for vertigo it was concluded that hearing testing followed by either
posturography or ENG (electronystagmography) was the most effective method
(Stewart et al, 1999).
• To detect central disorders. Recent studies have suggested that internuclear
ophthalmoplegia, a central eye movement disorder, is missed by 71% of physicians
unaided by quantitative oculomotor testing (Frohman et al, 2003).
• To decide if more expensive tests like MRI (Magnetic Resonance Imaging) are
needed. Vestibular testing is more accurate than clinical symptoms in predicting
whether neuroimaging tests will be abnormal.(Levy and Arts, 1996)
• To document objectively vestibular conditions such as BPPV and Perilymph fistula,
which commonly occur after head injury, vestibular neuritis, and Gentamicin
ototoxicity, which commonly is a side effect of medication.
 

What is the VENG Test?
Electronystagmography (ENG) is a study used to clinically evaluate patients with dizziness,
vertigo, or balance dysfunction. ENG provides an objective assessment of the oculomotor and
vestibular systems.
 

How is the test performed?
The test is performed with the patient wearing a set of video-goggles around the eye and
measuring the movements of the eye in relation to the ground electrode. The vestibular system
monitors the position and movements of the head to stabilize retinal images. This information is
integrated with the visual system and spinal afferents in the brain stem to produce the systems. A
newer standard for the recording is the use of infrared video vestibulo-ocular reflex (VOR). ENG
provides an objective assessment of the oculomotor and vestibular stems which allow for a more
detailed observation and analysis of these eye movements, called Video Nystagmography. A
similar test is performed for testing vertigo by using caloric reflex test, which can be induced by
air or water of specific temperatures, typically +/- 7 degrees Celsius from body temperature.
The standard ENG test battery consists of 3 parts:
• oculomotor evaluation
• positioning/positional testing
• caloric stimulation of the vestibular system
• The test can be performed in an examination room in less than 45 minutes.
• Using a light weight goggle outfitted with an Infra Red / Video camera, the horizontal and
vertical movements of the eye are displayed, saved and analyzed by the Windows based
computer system.

What is Hearing Testing?

Hearing testing is a means of evaluating an individual's overall hearing function. The
tests are used to determine if there is something wrong with the hearing (auditory) portion
of the inner ear. They are often used as an initial screening to decide if more expensive
tests like magnetic resonance imaging (MRI) are needed. They are sometimes used in
conjunction with vestibular testing to diagnose specific disorders, such as Meniere's
disease. Finally, hearing tests can be used to decide if a hearing aid might be helpful.

Pure tone audiometry
In pure tone audiometry, hearing is measured at frequencies varying from low pitches
(250 Hz) to high pitches (8000 Hz). This is just a part of the entire human auditory range,
which extends between 20 and 20,000 hz. Nevertheless, most audiometers are designed
so that they cannot go as low or high as most good stereo systems.
An example of an audiogram in a person with normal hearing is shown in figure 3. The
hearing level (HL) is quantified relative to "normal" hearing in decibels (dB), with higher
numbers of dB indicating worse hearing. The dB score is not really percent loss, but
nevertheless 100 dB hearing loss is nearly equivalent to complete deafness for that
particular frequency. A score of 0 is normal. It is possible to have scores less than 0,
which indicate better than average hearing. Pure-tone average (PTA) is the average of
pure tone hearing thresholds at 500, 1000, and 2000 Hz.
When there is a hearing loss, the next step is to try and determine whether the loss is
caused by a sensory problem (sensorineural hearing loss) or a mechanical problem
(conductive hearing loss). This distinction is made by using a bone vibrator, which
bypasses the mechanical parts of the middle ear. If hearing is better using bone than air,
this suggests a conductive hearing loss.

What is Hearing Tympanometry?

Tympanometry is a measure of the stiffness of the eardrum and thus evaluate middle ear
function. This test can be helpful in detecting fluid in the middle ear, negative middle ear
pressure, disruption of the ossicles, tympanic membrane perforation, and otosclerosis.

Acoustic reflex testing consists of subjecting the ear to a loud sound and determining if it
causes the stapedius muscle to tighten the stapes. Acoustic reflexes are mainly useful as
crude but non-subjective method of evaluating hearing, as the stapes should tighten for a
given level of perceived loudness. Acoustic reflexes can also be a sign of brainstem
dysfunction.

To perform the test, a soft probe is placed into the ear canal and a small amount of
pressure is applied. The instrument then measures movement of the tympanic membrane
(eardrum) in responses to the pressure changes.

The result of the test is recorded in a visual output, called a tympanogram. If there is fluid
in the middle ear, the tympanic membrane will not vibrate properly and the line on the
tympanogram will be flat. If there is air in the middle ear (the normal condition) but the
air is at a higher or lower pressure than the surrounding atmosphere, the line on the
tympanogram will be shifted in position.



What is OAE Testing?

OAE or otoacoustic emission testing is the recording of sounds that the ear produces
itself. Otoacoustic emissions were first reported by Kemp in 1978. They appear to be
generated by motile elements in the cochlear outer hair cells.

There are 2 types of otoacoustic emissions in clinical use:

• Transient otoacoustic emissions (TOAEs) or transient evoked otoacoustic
emissions (TEOAEs) - Sounds emitted in response to an acoustic stimuli of very
short duration; usually clicks but can be tone-bursts

• Distortion product otoacoustic emissions (DPOAEs) - Sounds emitted in response
to 2 simultaneous tones of different frequencies

The clinical significance of OAE's is that they only occur in a normal cochlea with
normal or near normal hearing. If there is damage to the outer hair cells producing mild
hearing loss, then OAEs are not evoked. A rule of thumb is that OAEs are present if
hearing is 35 dB or better. Because OAEs are evoked by transient signals that have a
wide frequency response, a broad region of the cochlea responds, providing information
on the frequency range from 1000 Hz to 4000 Hz. OAE's decline with age.(Gates et al.
2002; Cilento et al. 2003)

OAE's are appropriate for use in difficult-to-test patients: newborn infants, young
children, patients who are attempting to feign a hearing loss (i.e. malingering), and
developmentally delayed populations. OAEs primarily provide information about the
activity of the cochlea, and do not assess the status of the rest of the auditory pathway,
except for crossed responses mediated through the cochlear efferent system.

In adults, OAE's are most helpful in persons who may financially benefit from being
diagnosed with hearing loss, and also as a cross-check on audiometry. In our experience,
OAE's are very sensitive to noise and age related hearing disturbances.