糖心vlog

The COVID-19 pandemic has highlighted the importance of the diagnosis and management of olfactory dysfunction (OD)鈥攜ears into the pandemic, millions of patients likely continue to live with persistent alterations in smell.¹ This, of course, is in the broader context that more than 20% of the population has some degree of OD, a prevalence that is much higher in older adults. The effects of OD are broad reaching, with notable quality-of-life and psychosocial implications.² COVID-19鈥搑elated chemosensory loss in particular has also been shown to be associated with emotional distress and depression.³ In many patients, dietary and nutritional changes, as well as a reduced capacity to respond to danger signals such as smoke or toxic fumes, are consequences of OD. Moreover, olfactory loss is linked with faster declines in cognition in dementia-free older adults and a more than 50% higher all-cause mortality risk.²

To our knowledge and to date, however, no data have been published on OD health care utilization in the US. To address this, we searched the Vizient Clinical Data Base, with human participant exemption from the Johns Hopkins University Institutional Review Board. This quality-benchmarking database includes data as soon as 1 month after claims processing, and while not nationally representative, collects data from 97% of US academic medical centers and 160 community hospitals, comprising 609 hospitals in total. We evaluated the volume of office visits, including the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification code R43* for 鈥渄isturbances of smell and taste鈥� from October 1, 2018, to June 30, 2022, finding that visits for smell and taste disturbances increased 4- to 6-fold during the peak of the pandemic in 2020 and 2021 and continued to be about 50% higher in 2022 than they were in 2018 (Figure). These data are noteworthy because OD has often been dismissed as an unimportant or unrecognized condition, but recent evidence suggests that it may be a harbinger of comorbid conditions.^2,4 Additionally, OD also manifests with serious psychosocial implications of its own, and these new data on volume show greater numbers of individuals seeking care for changes in their smell.

This is a unique time when 2 major populations vulnerable to OD have grown: (1) older adults and (2) patients with COVID-19鈥揳ssociated OD, with acknowledged implications on lifespan and health span, respectively.⁵ Despite these data showing increases in health care utilization for OD, reimbursement for olfactory testing remains challenging. Without a dedicated Current Procedural Terminology code, physicians must bill for their services using the 92700 鈥渦nlisted otorhinolaryngological service or procedure鈥� code, which is rarely reimbursed by payers. In fact, of all major US health insurance payers, including the Centers for Medicare & Medicaid Services, only Aetna has a published Medical Clinical Policy Bulletin on olfactory testing, stating that it 鈥渃onsiders certain procedures/services medically necessary for the evaluations of members with unexplained olfactory dysfunction鈥�, [including] standardized olfactory tests such as the University of Pennsylvania Smell Identification Test (UPSIT) or 鈥楽niffin鈥� Sticks,鈥� the University of Connecticut Test Battery, the Pocket Smell Test, or the Brief Smell Identification Test. Other tests include Smell-Threshold Test, Smell-Suprathreshold Test, and Smell Unilateral Test.鈥�⁶ Aetna鈥檚 acknowledgment of medical necessity is an important first step, far beyond any other payer. That said, it does not guarantee reimbursement for formal olfactory testing, nor does it acknowledge that these different tests are highly variable in their staff time, supply costs, and clinical application. For instance, the UPSIT involves 40 different samples and considerable staff time and effort in administering the test, compared with 16 for the Sniffin鈥� Sticks battery.

Reimbursement for testing is a critical part of aligning incentives to ensure that patients receive appropriate workup and subsequent therapy for their conditions. While treatments for OD are currently limited, traditional measures such as olfactory training and corticosteroids may have some degree of efficacy.^2,7 More importantly, as newer therapies under active investigation such as olfactory cleft platelet鈥搑ich plasma injections, acupuncture, and stellate ganglion blocks come to fruition, it will be vital to ensure that physicians objectively collect and document OD. Furthermore, given the connection between olfaction (and possibly even predictive value) and cognition and pathological brain aging,⁸ it may be useful as a low-cost diagnostic measure for cognitive decline and frailty in older adults.⁹ A lack of proper reimbursement for olfactory testing makes these resource- and time-intensive assessments difficult for physicians to perform, especially in the setting of recent substantial Medicare payment cuts.¹⁰ Adequate reimbursement for testing would lead to improved evidence-based interventions and reduce inequities in the diagnosis and treatment of OD (particularly if these ultimately become out-of-pocket expenses for patients).

Moving forward, the approval of new reimbursement codes by the 糖心vlog鈥檚 Current Procedural Terminology Editorial Panel will require collaborative efforts, including grassroots organizations and patient advocacy groups like the Smell & Taste Association of North America and Fifth Sense, as well as professional otolaryngic expertise from the American Academy of Otolaryngology鈥揌ead and Neck Surgery and the American Rhinologic Society. This may ultimately need to be a J code instead of a full procedural code, but it would at least offer physicians reimbursement for supply costs. While this is a complex process that can take more than 2 years from start to finish, OD has a growing patient base that appears increasingly motivated to seek clinical care and an enormous variety of emerging treatment options. It represents an increasingly common presentation in the offices of both comprehensive otolaryngologists and fellowship-trained rhinologists, and it has real downstream implications in patients鈥� lives, as it is linked with anxiety, depression, nutrition, isolation, cognitive decline, frailty, and mortality. Now, with rising awareness of the condition, it is critical that the field advocate for appropriate reimbursement in the workup of this somewhat orphaned and difficult to treat condition.

Corresponding Author: Nicholas R. Rowan, MD, Department of Otolaryngology鈥揌ead and Neck Surgery, Johns Hopkins University School of Medicine, 601 N Caroline St, 6th Floor, Baltimore, MD 21287 (nrowan1@jhmi.edu).

Published Online: May 11, 2023. doi:10.1001/jamaoto.2023.0837

Conflict of Interest Disclosures: Dr Saraswathula is supported by a training grant from the National Institute on Deafness and Other Communication Disorders (2T32DC000027). Dr Schlosser reported personal fees from Stryker, Medtronic, Cyrano, Healthy Humming, NasoNeb, and Optinose outside the submitted work and is supported by a research grant from the National Institute on Deafness and Other Communication Disorders (5R01DC019078-01A1). Dr Rowan is supported by the Johns Hopkins University Claude D. Pepper Older Americans Independence Center, funded by the National Institute on Aging of the National Institutes of Health (P30AG021334).

Additional Contributions: We thank Ernie Shippey, MS, from Vizient for his support in data acquisition. He was not compensated for this contribution.