“This is regrettable, because a surgeon trained in FNM is in an ideal situation not only to perform the technical setup of monitoring but also to properly interpret the responses,” Dr. Kartush said. “Unlike a technologist in the room or a neurologist who may perform remote monitoring from home, only the surgeon is unequivocally attuned in real-time to how their surgical maneuvers correlate to the evoked potentials.”
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May 2014Dr. Kartush has argued at recent coding meetings of the American Medical Association that properly trained surgeons such as otolaryngologists are deserving of payment for FNM. The main problem, he said, is that otolaryngologists must demonstrate that intra-operative monitoring is indeed part of their core curriculum, and not just make a proclamation that monitoring is within the domain of the specialty. “Having published practice guidelines will help in that regard, further our national stance and enhance care,” he said.
As for the other specialties that are getting paid for FNM, including neurologists, audiologists, and neurophysiologists, they’ve successfully lobbied for those payments, Dr. Kartush said. “Frankly, that’s a political and advocacy challenge we need to better handle, working in concert with our professional societies.”
He acknowledged that reimbursement is a secondary concern, however, given the benefits of monitoring, as well as the relatively manageable cost of implementing FNM systems. A series of studies looked at this issue by assessing the clinical efficacy and cost benefits of FNM in middle ear and mastoid surgery. In one study, the researchers weighed quality-
adjusted life years (QALY) against the cost of care and found that a strategy employing FNM during primary and revision surgeries had the greatest effectiveness and lowest cost of all the strategies tested. Not monitoring the facial nerve had a lower QALY and the highest cost (Laryngoscope. 2003;113:1736-1745), the investigators reported. Based on the results, the authors concluded that FNM is indeed cost effective “and its routine use should be adopted to reduce the risk of iatrogenic facial nerve injury during otologic surgery.”
Poor monitoring is worse than no monitoring. That’s why practice guidelines that outline proper setup and interpretation are critical.—Jack M. Kartush, MD
Cost Not a Consideration
Peter S. Roland, MD, chair of the department of otolaryngology-head and neck surgery at the University of Texas Southwestern Medical Center in Dallas, agreed that cost should not be a major consideration in deciding whether to use FNM during most otologic procedures. “In our case, we’ve already purchased the system; our surgeons do the monitoring, and, frankly, if there is any expense associated with it, it’s something we just absorb, because the cost of not monitoring is so high,” he said.