section 1 application and justification strobocam ii · americans with disabilities act 1. internal...

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SECTION 1APPLICATION AND JUSTIFICATION

StroboCAM® IIFor diagnosis of laryngeal dysfunction

withEFFICACY, EFFICIENCY AND ECONOMY

Preface

Today, it is necessary to objectively document a diagnosis, results of treatment, and potential

for changes in laryngeal physiology and anatomy. In this litigious environment and fast-paced

lifestyle, quick, accurate diagnosis and simple treatment schedules are mandated by lawyers,

insurance companies, patients, and their physicians. Physicians can be more confident in total

patient care when they remain in control of the entire process of diagnosis, treatment and cure.

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Introduction

Executive Overview

• Through Strobovideolaryngoscopy, each otolaryngology office can affordably do studies of individual and successive phases of motion of the larynx

• StroboCAM® II is a revolutionary NEW camera without the costly flashing light and without a costly computer based system

• Affordable new technology costing $18,500 for the complete system which includes digital DVD recording.

• Utilized for examination / observation of successive phases of motion of the larynx

• A necessary diagnostic procedure that is efficacious, efficient, economical • Faster diagnosis, reduce second opinions, confident conclusions • Earlier treatment of potentially serious disease • Convenience facilitates compliance of patient diagnosis and treatment • You maintain complete control of diagnosis, treatment and follow-up • Investment that positively impacts practice revenue

• Videostroboscopy, the AAO-HNSF position from March 1, 1998 • Strobovideolaryngoscopy...CPT code # 31579 • Valuable in diagnosis, effective, it is not investigational • Clearly defined clinical indicators based on ICD-9 codes • Should not be performed on a separate visit in a separate endoscopy suite

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MATERIALS AND METHODS

Executive Overview

• Several publications, articles and continuing medical education are available for the training of physicians

Videoendoscopy from Velopharynx to LarynxMichael P. Karnell

Videostroboscopic Examination of the Larynx (recommended)Hirano and Bless

Video Laryngeal Stroboscopy - A Multimedia Tutorial CD-ROMBless and PoburkaSingular Publishingwww.singpub.com

CoursesTypically the American Academy of Otolaryngology Head and Neck Surgery Foundation (AAO-HNSF)

will offer courses at their annual congress

• Simple equipment - StroboCAM® II, patient chair without headrest, stroboscopic evaluation form.

• Oral endoscopy is the most efficient approach (84% of the time) with no anesthesia needed. StroboCAM® II will strobe with rigid and flexible scopes however.

• The highly mobile StroboCAM® II system is calibrated and positioned quickly. The patient preparation is brief and in 5-10 minutes you can be ready to begin the exam.

• With the patient leaning slightly forward, the chin is lifted and the scope is positioned easily along the upper incisors. Speech sampling is done and final positioning captures the images of the vocal folds through focus adjustment on the scope adaptor.

• A 12-point evaluation/observation is made and from this evaluation, the physician can make a laryngeal assessment. This evaluation is recorded on a sample form. (See pg. 7 )

• The operation of the StroboCAM® II unit is really quite simple, and through the use of a foot pedal and a couple of buttons on the console you can complete the exam.

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RESULTS

Executive Overview

• Continuing education for videostroboscopy is abundant and available in the form of seminars, publications, and literature.

• No special office physical set up is necessary due to small footprint, mobility of equipment and use of existing patient chair.

• Cost of equipment based on this new technology is $18,500, about 50% less than the computer based technology.

• StroboCAM® II will work in the stroboscopic mode and has a standard video mode so you can use the standard video system with the laryngoscope or any other scope, such as an otoscope or a sinus scope.

• Digital DVD recording capabilities enhance documentation of conditions and enhance patient education, and can even qualify for tax breaks under the Americans with Disabilities Act (enclosed).

• This system and the associated observation and examination can identify potential serious conditions and permit a faster diagnosis, have treatment begin earlier, provide patients with the convenience of examination, diagnose and treat in one office, and have complete control of the follow-up evaluation of treatment.

• Filing claims under CPT code 31579 can produce a reimbursement ranging from $207-$301 for Medicare to $300+ from private insurance groups, and the procedure can be done up to three times. This can generate up to $12,000+ monthly.

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DISCUSSION

Executive Overview

• Implementing videostroboscopy is divided into 2 easy phases:

1. Further development of knowledge from publications, seminars, articles and CD-Rom tutorials.

2. Acquiring the StroboCAM® II system using one of JEDMED’s comfortable payment plans.

• Easily implemented by any office

• Videostroboscopy is the only suitable way to assess visible AND subtle changes in vocal folds or vibratory patterns

• StroboCAM® II new technology with compact design, digital DVD recording, and mobility provides every office with the opportunity to provide improved diagnosis and treatment for many patients.

• This can all be accomplished with a substantial increase in practice revenues and quick return on investment.

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CONCLUSION

“Today, with the concept of accountability and the reality of litigation, it is necessary to objectively document the results of treatment and the potential for further change. Objective measures not only provide unbiased documentation of change but also provide information that neither the eye nor the ear is capable of discerning. Thus, voice assessment is indicated pre-treatment and post-treatment for all dysphonic patients, for patients whose diagnosis is questionable, and for those whom decisions on the potential for changes through behavior must be made.”

Through the use of proven techniques and with the aid of the NEW technology in JEDMED StroboCAM® II, these all-important diagnostic sequences can become reality - a reality that you will find to be efficient, efficacious and profitable regardless of your practice location or situation.

Michael P. Karnell, Videoendoscopy: From Velopharynx to Larynx, Singular Publishing Group Inc., San Diego, 1994.

Minoru Hirano and Diane M. Bless, Videostroboscopic Examination of the Larynx, Singular Publishing Group Inc., San Diego, 1993, pp. 92.

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Glottic Closure

Cannot

RateComplete Anterior Irregular

Spindle Posterior Hourglass Incomplete

STROBOSCOPIC EVALUATION

Supraglottic Activity

Latero-Medial

Compression (0) (1) (2) (3)None Mild Mild-Mod Moderate compression of vent. folds

(4) (5) (6)Mod-Severe Severe Dysphonia Plica Ventricularis TVF not visible

(0) (1) (2) (3)None Mild Mild-Mod Moderate

(4) (5) Mod-Severe Severe

Antero-Post

Compression

Voice Quality

Normal Mildly Dysphonic Mild-Mod Dysphonic

Moderately Dysphonic Mod-Severely Dysphonic

Severely Dysphonic Aphonic

Vertical Level Approx

(0) (1) (2)

Cannot Rate Equal Right Lower

(3) (4)

Left Lower Questionable

Vocal Fold Edge

LEFT (0) (1) (2) (3) (4) (5) (6)

Cannot Smooth Rough

Rate Straight Irregular

Right (0) (1) (2) (3) (4) (5) (6)

Vocal Fold Mobility

LEFT (0) (1) (2) (3) (4)

Cannot Normal Limited Limited Fixed

Rate Adduction Abduction (mild)

(mild) (mod) (mild) (mod) (mod)

(sev) (sev) (sev)

RIGHT (0) (1) (2) (3) (4)

Amplitude

RIGHT

(0) (1) (2) (3) (4)

Cannot Normal Mildly Mild-Mod Mod

Rate Decreased Decreased Decreased

(5) (6) (7)

Mod-Sev Severely No Visible

Decreased De creased Movement

LEFT

(0) (1) (2) (3) (4)



(5) (6) (7)

Mod-Sev Severely No Visible

Decreased De creased Movement

Mucosal Wave

LEFT

(0) (1) (2) (3) (4)



(5) (6) (7)

Mod-Sev Severely Absent

Decreased Decreased

RIGHT

(0) (1) (2) (3) (4)



(5) (6) (7)

Mod-Sev Severely Absent

Decreased Decreased

Non-Vibrating Portion

LEFT

(0) (1) (2) (3) (4) (5)

None 20% 40% 60% 80% 100%

RIGHT (0) (1) (2) (3) (4) (5)

Phase Closure

(-5) (-4) (-3) (-2) (-1) (0)

Cannot Open Phase Nor mal

Rate Predominates

(Whisper

dysphonia)

(1) (2) (3) (4) (5)

Closed Phase

Predominates

(Glottal fryextreme

hyperadduction)

Phase Symmetry

Cannot

Rate

Regular

always

sym met ri cal

Irregular

during

end or begin

tasks

Irregular

during

extremes

pitch or loud

(0) (1) (2)

50%

asym met ri cal

75%

asym met ri cal

always

asym met ri cal

(3) (4) (5)

Overall Laryngeal Function

Normal Hy po func tion Hy per func tion

(0) (1) (2)

Laryngeal tremors

(sust. v) (speech)

(mild) (mod)

(severe)

Phonatory spasms

(add) (abd)

(mild) (mod)

(severe)

(3) (4)

Patient Name: Doctor/Technician:

Age: Date:

Sex: M F

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DIAGRAMOFMUCOSALWAVE

Frontal ViewCross Section

View FromAbove

C5

O1

O2

O3

O4

O5

C1

C2

C3

C4

Phase

complete glottal closure

Note differentcontact points

earlystage

maximum

bestoverallview

butclosing

butclosing

Best overallview

greatest glottal width

C = closedO = open

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SECTION 2BACKGROUND AND SUPPORT

AAO-HNS Policy Statement - 3/1/98

Subject: The Role of Flexible Laryngoscopy, Videostroboscopy, and Strobovideolaryngoscopy in the Office Evaluation, and Management of

Patients With Otolaryngic Disorders

Strobovideolaryngoscopy (31579) is a well-established diagnostic procedure that is medically indicated for the diagnosis of voice, swallowing and airway disorders. This procedure requires the application of distinct endoscopy skills, training and judgment resulting in the gathering of unique information in the functional and anatomic assessment of the upper airway. These examinations can be performed in the office without taking the patient to the operating room or the endoscopy suite. The value of the procedure in diagnosis and management of otolaryngic disorders is effective and they are not investigational. Some patients may require one or more of these diagnostic procedures performed individually or sequentially. The extended nature of examination of the structure and function of the upper aerodigestive tract is often comprehen-sive and complex. The endoscopic evaluation of the upper airway should not be considered part of the routine office examination.

• Videostroboscopy should not be considered a routine part of the initial visit.

• Videostroboscopy should not be required to be done as a separate return visit.

• Videostroboscopy should not be mandated to be performed in a separate endoscopy suite or outpatient surgery center in order to be reimbursed.

Clearly defined clinical indicators based on ICD-9 diagnostic code groups have been developed in the literature to support the above positions.

Some of the more common indications are:

Persistent Hoarseness

Suspected Neoplasm

Chronic Cough

Hemoptysis

Hemorrhage from Throat

Throat Pain

Dyspnea

Stridor

Dysphagia

Laryngeal Injury

Chronic Aspiration

Velopharyngeal Incompetence

Suspected Foreign Body

History of Tobacco Use

Gastroesophogeal Reflux

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“ “

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CODES ASSOCIATED WITH STROBOVIDEOLARYNGOSCOPY

CPT31579 Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy92506 Evaluation of speech, language, voice, communication, auditory processing and/ or aural rehab92507 Treatment of speech, language, voice, communication, auditory processing and/ or aural rehab (individual)92508 Group two or more92520 Laryngeal function studies

e.g. 31579 + 92520 = laryngoscopy, flexible or rigid fiberoptic, w/stroboscopy including laryngeal function studies

Modifiers09955 or -55 post op09956 or -56 pre op09957 or -57 deciding for surgery

ICD-9472.1 Pharyngitis (chronic)478.3 Paralysis478.31 Paralysis / Unilateral478.34 Paralysis / Bilateral478.4 Vocal fold / Polyps478.5 Vocal fold / Other diseases (nodules, granuloma...)478.6 Laryngeal edema478.75 Laryngeal spasms478.79 Dysphonia / Spastic530.11 GER784.41 Aphonia784.49 Hoarseness786.2 Cough462.0 Pharyngitis (acute)464.0 Laryngitis (acute)476.0 Laryngitis (chronic)

CPT Code Modifiers Associated With Strobovideolaryngoscopy (31579)-26 or 09926 technical and professionalfor instance: speech pathologist performs and bills for strobovideolaryngoscopy copy (31579) physician reviews exam and bills using modifier (31579-26) this is normally accepted if the billings come from separate offices or facilities -55 or 09955 used when stroboscopy is part of post-operative review-59 or 09956 used when stroboscopy is performed pre-operatively-57 or 09957 used when making a surgical decision

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AMERICANS WITH DISABILITIES ACT

1. Internal Revenue Code CITE 26 USC SEC. 44, TITLE 26, SUBTITLE A, CHAPTER 1, SUBCHAPTER A, PART IV, SUBPART D, SECTION 44 - Expenditures to provide access to disabled individuals.

a. GENERAL RULE For purposes of section 38 in the case of eligible small business, the amount of disabled access credit determined under this section for any taxable year shall be an amount equal to 50% of so much of the eligible access expenditures for the taxable year as to exceed $250.00, but do not exceed $10,250.00.

b. ELIGIBLE SMALL BUSINESS 1. In general, means amount paid or incurred by an eligible small business for the purpose of enabling such eligible small business to comply with the Americans with Disabilities Act of 1990.

A. For the purpose of removing architectural, communication, physical or transportation barriers which prevent a business from being accessible to or usable by individuals with disabilities

B. To provide interpreters or other effective methods of making aurally delivered materials available with hearing impairments

C. To provide interpreters or other effective methods of making visually delivered materials available with hearing impairments.

D. To acquire or modify equipment or devices for individuals with disabilities

E. To provide other similar devices, modifications, materials, or equipment

2. Federal Register

VOL. 56/NO. 144/FRIDAY, JULY 26, 1991 - RULES AND REGULATIONS Section 36.302 of the rule prohibits the failure to make reasonable modifications in policies, practices, and procedures when such modifications may be necessary to afford any goods, services, facilities, or privileges, advantages, or accommodation....to a disabled person. This prohibition is based on section 302(b)(2)(A)(ii) of the ADA.

Section 36.303 Auxiliary Aids and Services requires a public accommodation to take such steps as may be necessary to ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than other individuals because of the absence of auxiliary aids and services...This requirement is based on section 302(b)(2)(A)(ii) of the ADA.

Implicit in this duty to provide auxiliary aids and services is the underlying obligation of a public accommodation to communicate effectively with its customers, clients, patients, or articipants who have disabilities affecting hearing, vision, or speech.

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SECTION 3CALCULATION OF FINANCIAL JUSTIFICATION

Strobovideolaryngoscopy is justified and supported by the AAO-HNSF. Insurance providers recognize the extra effort and reimburse accordingly.

To that end a calculation is necessary to determine the return on investment a practice will realize for the addition of stroboscopy equipment.

The return on investment (ROI) equation on the next page will assist in the final decision.

www.cms.gov This is the website to look up the Medicare reimbursement for a specific region

31579 Direct Laryngoscopy with Stroboscopy

43200 Esophagus Endoscopy

92612 FEES

92616 FEESST

91614 Sensory Swallow Test

HERE IS THE INFORMATION ON HOW TO:

1 Highlight PROFESSIONALS, scroll down and click on PHYSICIANS

2 Scroll down to MEDICARE PHYSICIAN FEE SCHEDULE LOOK-UP and click

3 Scroll down to bottom of License page and click on ACCEPT

4 Scroll down to bottom of next page and click on START

5 Choose SINGLE, LIST or RANGE of codes and PRICING INFO then click NEXT

6 Choose SPECIFIC LOCALITY and DEFAULT FIELDS (PRICING ONLY) then click NEXT

7 Enter the code number(s), choose ALL MODIFIERS then choose CARRIER LOCALITY for your region then click on SUBMIT

8 Scroll down the next page to find payment schedule for services

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$254 (average)

16

Patients per day that are candidates for stroboscopy

Number of open office daysper month

Number of patients thatare not referred away from office

Amount of reimbursement forstrobovideolaryngoscopy (CPT 31579)(refer to regions on next page)

YOUR MONTHLY ROI

(refer to this number as your Individual Practice Factor, IPF)

Write the IPF# at the top of page #16

ROIRETURN ON INVESTMENT CALCULATOR

X

X

Example:

= 32

2

$8,128

Now Enter Your Numbers Here

=

X

X

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MEDICARE REIMBURSEMENT BY REGION*CPT 31579

STROBOVIDEOLARYNGOSCOPY

$195$234

$221

$291

$268 $216

$223

$226

$211

$231

$210

$229

$198

$196

$210

$196

$200

$241

$238

$207

$196

$206

$198

$227

$219

$234$250

$209

$202

$195

$223

$197

$206 $217

$201

$267

$240

$195

$196

$196

$198

$193$190

$215

$193$194

$201

$213$204

$209

$199

$204

$263$219

$241$220

$232

$230

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PURCHASING ALTERNATIVES

IPF# (Your IPF# from page 14)

Plan A......20% down with order / balance due net 30 days

Plan B....Deferred Financing with $1.00 purchase option

Plan C.....Deferred Leasing with 10% purchase option

If you choose payment Approx. payment 3 yr plan Months 1-3 $0 Months 4-39 $566

4 yr plan Months 1-3 $0 Months 4-51 $444


If you choose payment Approx. payment 3 yr plan Months 1-3 $0 Months 4-39 $610



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PURCHASING ALTERNATIVES

A simple return on investment chart based on a 36 month deferred lease with 10% buyout

Monthly total return on StroboCAM® II investment 12

patients/screenings per month@ $254 each

$3,048 39 month total return on StroboCAM® II investment

$118,872

Lease payment each month (approx)

- $566 Lease payment36 months + $1699 (10% buy out)

- $23,227

Monthly net return for each month

$2,450 Net return for 39 months $95,645

The factor of 12 patients per month is really quite low, given the great number of clinical indi-cators based on the ICD-9 codes listed. Many practices will see more patients that will have conditions indicating the need for Videostroboscopy. Furthermore, each patient may require 2-3 individual examinations to evaluate treatment and final results.

The relative short learning curve and minimal up front investment needed to begin utilizing the full benefits of Videostroboscopy make the system and approach very attractive for every otolaryngology office.

Videostroboscopy represents the only suitable way to assess a client’s visible change in physiology. It is most important in cases in which pathology is subtle and not demonstrated adequately with observation of vibratory pattern of the vocal folds.

The set-up and operation of StroboCAM® II is fast and easy and the system provides excellent images of the larynx, surrounding tissues and vocal folds during phonation.

The relative compact design, low cost for the system and mobility of the platform offers many features that have not been available before. The new technology provides every office a NEW efficient, efficacious and economical way to bring diagnosis and treatment to many patients who have entrusted us with their care.

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StroboCAM®Return on Investment

3 year lease with 10% buyout

section 1 application and justification strobocam ii · americans with disabilities act 1. internal...

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