Physician extenders: Which one is right for you?
Mr. Strickland is the Administrative Director in the Department of Radiology, University of Virginia, Charlottesville, VA.
With the continued growth of imaging, an increasing number of radiologists are turning to physician extenders. The American College of Radiology's Task Force on Human Resources estimated that the workload for radiologists is increasing 6% each year while the number of radiologists is rising only 2% per year. 1 Radiology departments and practices realize that if they are unable to meet the demand, other specialties will move to absorb the volume. Radiology practices have the option of hiring many types of physician extenders in their attempts to meet this demand. The most frequently utilized are physician assistants (PAs), nurse practitioners (NPs), radiology practitioner assistants (RPAs), and radiologist assistants (RAs). Each of these can act as a physician extender, but each is unique in terms of qualifications, scope of practice, malpractice coverage, and/or the ability to bill for his/her services. This manuscript will provide a description for each type of physician extender, their utility, and their limitations.
Physician assistants have been in practice since the 1960s. They are licensed healthcare professionals who directly provide medical care under physician supervision. Dr. Eugene Stead of Duke University established the first academic PA program and graduated the first class of PAs in 1965. 2 The average program is approximately 26 months long. Most of the 130 U.S. programs require a bachelor's degree and previous health-care experience as prerequisites for entrance. The professional organization for PAs is the American Academy of Physician Assistants (AAPA). Certified PAs hold the title of Physician Assistant, Certified (PA-C). PAs are employed in all 50 states.
According to the Medicare Carrier's Manual, a PA is qualified if the PA graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and meets all applicable state laws. 3 The Centers for Medicare & Medicaid Services (CMS) defers to each state's regulations regarding licensure. Thus, to meet the CMS definition of a qualified PA, a PA must meet both the federal and state requirements.
Scope of practice
The scope of practice of a PA corresponds to the supervising physician's practice and the applicable state laws. Typically, PAs can conduct physical examinations, diagnose and treat illnesses, order tests, interpret tests (including radiological studies), and assist in surgery. They can also prescribe medications in 48 of the 50 states.
The general AAPA guidelines were developed by the American Medical Association (AMA) House of Delegates in June 1995. They are: 1) Healthcare services delivered by physicians and PAs must be within the scope of each practitioner's authorized practice as defined by state law. 2) The physician is ultimately responsible for coordinating and managing the care of patients and with the appropriate input of the PA, ensuring the quality of healthcare provided to patients.
3) The physician is responsible for the supervision of the PA in all settings.
4) The role of the PA in the delivery of care should be defined through mutually agreed-upon guidelines that are developed by the physician and the PA and are based on the physician's delegatory style. 5) The physician must be available for consultation with the PA at all times, either in person or through telecommunication systems or other means. 6) The extent of involvement by the PA in the assessment and implementation of treatment will depend on the complexity and acuity of the patient's condition and the training, experience, and preparation of the PA as adjudged by the physician.
7) Patients should be made clearly aware at all times whether they are being cared for by a physician or a PA.
8) The physician and the PA should review all delegated patient services on a regular basis, as well as the mutually agreed-upon guidelines for practice. 9) The physician is responsible for clarifying and familiarizing the PA with his/her supervising methods and style of delegating patient care. 2
The scope of practice is also regulated at the facility level (ie, hospital, office, independent diagnostic testing facility, etc.), based on the credentialing requirements for PAs. If the facility's requirements are more restrictive than the AMA requirements, then the facility's requirements should be followed.
In radiology practices, PAs are used primarily to assist in, perform, and monitor patients undergoing interventional radiology procedures (such as central venous access, angioplasty, and embolization). Since physicians are responsible for supervising PAs, radiology practices typically employ PAs. However, PAs may be employed as independent contractors rather than employees to minimize malpractice exposure. 4 Hospitals can employ PAs and be covered under their institutional policy.
Ability to bill for their services
PAs can receive their own provider numbers for Medicare. CMS has designated specific levels of physician supervision for diagnostic tests to be eligible for billing to Medicare. These levels and rules must be followed in a nonhospital setting for reimbursement:
General --The test must be performed under the supervising physician's overall direction and control. The physician's presence is not required.
Direct --The supervising physician must be present in the office suite and immediately available to furnish assistance and direction.
Personal supervision --The supervising physician must be in attendance in the room during the performance of the procedure. 5
It is important to note that these rules apply only to nonhospital settings. If state law and institutional policies allow, reimbursement requirements are different in hospital settings. If the physician is present in a hospital setting, then the services can be billed in the physician's name and reimbursed at 100% of the Medicare Fee Schedule. If the supervising physician is not present, the service can be billed in the PA's name and will be reimbursed at 85% of the Medicare Fee Schedule. (Commercial payors rules vary. An individual practice should consult with its commercial payors to determine if there is coverage for PA services.)
In an academic setting, a PA (or other physician extenders) can train house-staff (ie, residents and fellows) but cannot supervise them for billing purposes. Thus, a service performed by a house-staff member and supervised by a PA is not a billable service for Medicare.
Nurse practitioners (NPs)
Nurse practitioner programs began in 1965 at the University of Colorado. An NP is a registered nurse with clinical experience who has obtained a master's degree. There are more than 200 academic NP programs nationwide. Nurse practitioners are licensed as nurses as well as NPs and are employed in all 50 states. They can prescribe medication in at least 42 states. NPs may have specialty training in areas such pediatrics, family medicine, obstetrics/gynecology, and acute care. One of the NP organizations is the American College of Nurse Practitioners (ACNP). NPs are certified by several programs, such as the American Nurses Credentialing Center, the National Certification Board of Pediatric Nurse Practitioners and Nurses, and the American Academy of Nurse Practitioners. 6
According to the Medicare Carrier's Manual, NPs must be licensed professional nurses who possess at least a master's degree in nursing with appropriate NP clinical hours and didactic education accepted in the state where they work and must meet the other state requirements to qualify as an NP in that state. An example of one of the state requirements is that the individual must also be certified as an NP by an accepted national certifying body.
Again, CMS defers to each state's regulations for licensure of NPs. Thus, to meet the CMS definition of a qualified NP, an NP must meet the state requirements to be eligible for federal reimbursement.
Scope of practice
Generally, the scope of practice of an NP is similar to that of a PA in that NPs, by state law, typically can conduct physical examinations, diagnose and treat illnesses, order and diagnose tests (including radiologic studies), and educate patients. They can also prescribe medications in at least 42 states. NPs typically perform activities as defined by their written agreement with the supervising physician(s). The ACNP defines the Scope of Practice for Nurse Practitioners as follows: "Nurse practitioners are primary care providers who practice in ambulatory, acute, and long-term care facilities. According to their practice specialty, these providers provide nursing and medical services to individuals, families, and groups. In addition to diagnosing and managing acute episodic and chronic illnesses, NPs emphasize health promotion and prevention. Services include, but are not limited to, ordering, conducting, supervising, and interpreting diagnostic and lab tests, and prescription of pharmacologic agents and nonpharmacologic therapies." 7
Physicians employ the NP and are typically responsible for supervising NPs in nonhospital settings. If the NP is not performing in a true physician extender role but in more of a medical management role, then hospitals typically employ the NPs. However, it is possible to hire NPs as independent contractors instead of as employees, to minimize malpractice exposure.
Ability to bill for their services
NPs can obtain their own provider numbers for Medicare and must meet the same requirements as PAs with respect to the CMS-designated levels of physician supervision for diagnostic tests. They must also meet this direct level of supervision in a nonhospital setting.
Again, if state law and institutional policies allow, reimbursement requirements are different in hospital settings. If the physician is present in a hospital setting, then the services can be billed in the physician's name and will be reimbursed at 100% of the Medicare Fee Schedule.
If the supervising physician is not present but is immediately available, then the service can be billed in the NP's name and will be reimbursed at 85% of the Medicare Fee Schedule. (Commercial payors rules vary. Consult with your commercial payors to determine if there is coverage for NP services.)
In an academic setting, an NP, like all other physician extenders, can train housestaff (ie, residents and fellows) but cannot supervise them for billing purposes. Thus, a service performed by a housestaff member and supervised by an NP is not a billable service for Medicare.
Radiology practitioner assistants
Radiology practitioner assistants were first developed in the 1970s. The concept has always been to expand the education and role of radiologic technologists. The University of Kentucky and Duke University developed advanced training programs for radiologic technologists. When federal funding ended, so did the programs. In 1994, the Department of Defense approached Weber State University in Utah to create a radiology assistant program to address the radiologist shortage in the military. Once again, federal funds ended, but Weber State was able to offer the first RPA class in 1996. 8 RPAs are now employed in at least 42 states. 9
An RPA is an individual who is certified by the American Registry of Radiologic Technologists (ARRT) and has successfully completed an RPA program recognized by the Certification Board for Radiology Practitioner Assistants (CBRPA). 9 According to CBRPA, RPAs are credentialed to provide primary radiology healthcare with radiologist supervision. While PAs and NPs can practice outside of the specialty of radiology, RPAs are limited to radiology or other imaging specialties.
As noted previously for PAs and NPs, CMS defers to states' regulations regarding licensure of healthcare professionals. RPAs do not receive a separate license; in most states they are licensed as radiologic technologists. Thus, RPAs, like registered technologists-radiography (RT(R)s), are not currently recognized as independent practitioners according to the definition of the Medicare Carrier's Manual.
There is activity in several states to modify the RPA licensure and scope of practice. For example, RPA (and RA) legislation was recently introduced in the state legislatures of Tennessee, 10 Kentucky, 11 and Washington, to name a few. This expansion is important for professional and malpractice reasons, as will be discussed below.
Scope of practice
The CBRPA defines the RPA's scope of practice based on the curriculum of the RPA program. RPAs cannot provide a final interpretation. It states that "The professional educational curriculum prepares [RPA] graduates to, but are not limited to:
1) Provide a broad range of radiology healthcare services under the supervision of an ABR-certified radiologist;
2) Assess and evaluate the physiologic and psychologic responsiveness of each patient;
3) Participate in patient management, including prescriptive powers for imaging procedures;
4) Administer intravenous medications or contrast media, under the supervision of a certified radiologist, and record documentation in medical records;
5) Perform fluoroscopic procedures, both dynamic and static;
6) Perform specialized imaging procedures, including invasive procedures, after demonstrating competency, under the supervision of a certified radiologist;
7) Evaluate and screen medical images for normal versus abnormal findings and provide a technical report to the supervising radiologist;
8) Maintain values congruent with the Code of Ethics, as well as adhering to national, institutional, and/or departmental standards, policies, and procedures regarding the standards of care for patients." 12
In most states, an RPA is recognized as an RT(R) and can be employed by either the hospital or the radiology practice. (New York is one exception where RPAs are recognized as "specialized assistants.") Most employers obtain malpractice coverage for an RT(R). The malpractice insurance may be limited to those services covered under the license of the RT(R) in that state.
It is important to note that when RPAs perform a procedure, they not only must be credentialed to perform that procedure but they must also be licensed to perform that procedure, or the supervising physican may also be liable. As Joy Delman, JD noted, "If a physician provides medical treatment through the aid of someone who holds himself or herself out as a licensed assistant [to perform that procedure] and the physician knows the assistant is not so licensed, then the physician is guilty of aiding and abetting the unauthorized practice of medicine." 13
For this reason, it is critical for malpractice purposes that state legislation must be modified to allow RT(R)s and/or RPAs to be licensed to perform procedures expected in a radiology department or practice.
Ability to bill for their services
In most states, an RPA cannot bill for his/her services. An RPA can function in the capacity of an RT and bill for the technical component of imaging studies under the CMS guidelines. To bill for the professional component of a study or procedure, an RPA must be under the direct or personal supervision of a physician. This requirement is similar to those of resident supervision in academic medical center settings. For example, an RPA can provide a preliminary interpretation but the images must be reviewed by the radiologist in order to bill for the professional component. Depending on individual state licensure, surgical procedures may be performed but should meet the billing requirements of major and minor procedures for CMS. As the state licensure for RPAs expand, the ability to bill for RPA procedures may follow.
Radiology assistants are the newest type of physician extender. In March 2002, an Advanced Practice Advisory Panel met in Washington, DC and drafted the consensus paper, "The Radiologist Assistant: Improving Patient Care While Providing Workforce Solutions and ACRASRT Joint Policy Statement Radiologist Assistant; Roles and Responsibilities." 14
In January 2003, the ASRT Foundation awarded $25,000 educational grants to four educational institutions to launch RA educational programs. The first four were: Loma Linda University (Loma Linda, CA), Midwestern State University (Wichita Falls, TX), the University of North Carolina at Chapel Hill (Chapel Hill, NC), and the University of Medicine and Dentistry of New Jersey (Newark, NJ).
At least 9 other institutions have subsequently developed or are now developing RA programs. 15 The ACR Intersociety Conference met in August 2003 and endorsed the ACR-ASRT Joint Statement. The first RA classes should graduate in the Summer of 2005.
The Medicare Carrier's Manual does not consider RAs to be independent practitioners.
The ACR-ASRT panel wrote 12 consensus statements covering issues such as education, experience, and supervision. The Consensus Statement on Title and Definition states the following: "A radiology assistant is an advanced-level radiologic technologist who enhances patient care by extending the capacity of the radiologist in the diagnostic imaging environment." 14
RAs will receive 2 years of a didactic and clinical education in a program accredited by the ARRT. The ARRT is finalizing RA certification and plans to have the program available in September 2005. 16 RAs and RPAs are being paired with one another in state legislative actions.
Scope of practice
The ARRT and the ACR define the RA as "an advanced-level radiographer who works under the supervision of a radiologist to promote high standards of patient care by assisting radiologists in the diagnostic imaging environment." 14 The RA Role Delineation includes clinical activities but does not include performing interpretations. It ranges from patient assessments, patient management, and selected examinations. The ARRT has defined the supervision of the RA using the General, Direct, or Personal definitions of CMS.
RAs are considered clinical extensions of RT(R)s. In most states, RAs would be licensed as RT(R)s and, therefore, should be hired as such. RAs can be hired as "supertechs" and provide the technical component of services. Since they are not independent practitioners, however, they can only perform those activities that a licensed RT(R) can perform. For RAs to practice in the scope defined by the ARRT, state legislative changes will need to be made regarding RA licensure.
Ability to bill for their services
In most states, an RA cannot bill for his/her professional services. An RA can function in the capacity of an RT and bill for the technical component of imaging studies under the CMS guidelines. To bill for the professional component of a study or procedure, an RA must be under the direct or personal supervision of a physician. This is still subject to facility and state regulations. Again, this requirement is similar to those of resident supervision in academic medical center settings. As the state licensure for RAs expands, the ability to bill for RAs may follow.
The various types of physician extenders are professionals who have obtained additional education to meet the requirements of his/her specialty. Each is limited by state law in terms of licensing and scope of practice. Physician extenders are governed locally by the credentialing requirements of the organization in which they work and their supervising physicians' scope of practice. The federal government, via CMS, determines if payment can be made based on the supervision rules and acknowledgement of the specialty as an independent practitioner. All of these factors must be taken into consideration in determining which of these physician extenders, if any, are best for your practice.