The term Physician Extender can include a Radiologist Assistant (RA), a Physician Assistant (PA), or a Nurse Practitioner (NP). The rules for use of these Non-Physician Providers (NPP) are different for each one and they vary from state to state according to their licensure laws. In some cases, the practice may bill and be reimbursed separately for the services of a NPP. Understanding the differences is key to getting started with physician extenders.
Non-Physician Providers
A Registered Radiologist Practitioner Assistant, abbreviated RA, RRA or RPA, is trained initially as a radiologic technologist and then achieves additional training and credentialing. The American Registry of Radiologic Technologists (ARRT) certifies RRA’s. They work under the supervision of a radiologist and serve as an assistant to perform patient assessment, patient management, and selected clinical imaging procedures. They are not qualified to perform any level of imaging interpretation, but they may make observations in communication with the supervising radiologist. The ARRT maintains an Entry Level Clinical Activities list that describes the procedures a RRA might perform, subject to any limitations imposed by state licensing and/or the individual practice’s desires.
The capabilities of a PA or NP are similar to each other, and both are governed by state licensing as to their scope of practice. Both PA’s and NP’s may obtain National Provider Identification (NPI) numbers that allow their services to be reimbursed by Medicare. In some states, an NP may practice independently, but generally both NP’s and PA’s work in collaboration with a physician practice. In our experience PA’s are the most common physician extenders in radiology practices, usually providing services along with interventional radiologists (IR).
Services in Radiology Practices
The services that may be provided by NPP’s is governed by state law and also by hospital credentialing rules. It is most important to be aware of the scope of practice available through the licensure in the state where your practice operates, and also to check with the hospital before having NPP’s provide services in your practice. Generally, however, NPPs will be able to perform minimally invasive procedures such as paracentesis, thoracentesis, percutaneous biopsies, and central venous access. They would also be able to assist with evaluation and management (E/M) visits with IR patients.
Supervision and Reimbursement
The rules related to supervision and reimbursement of NPPs have been changing over the past few years. The 2019 Medicare Physician Fee Schedule (MPFS) allowed RRA’s to perform diagnostic tests under Direct Supervision, an upgrade from Personal Supervision that now allows the radiologist to now be simultaneously productive in other ways. In 2020 Medicare began to allow both PA’s and NP’s to supervise the performance of diagnostic testing within their scope of practice and state law. Pending legislation known as MARCA (the Medicare Access to Radiology Care Act) would provide Medicare reimbursement for the non-diagnostic services of RRA’s. All of these Medicare regulations are predicated on the ability of the NPP to perform the specific service within the scope of their state licensure.
The ability to bill and be reimbursed for the services of NPP’s varies depending on the site of service. PA’s and NP’s, as providers with NPI numbers, may perform services and the practice may be reimbursed for those services. However, reimbursement for the services of RRA’s who are not considered to be providers is included in the technical component (TC); in the hospital, the TC is paid to the hospital facility while in the office the TC is included in the global payment to the practice.
In the IR setting, PA’s and NP’s may assist the radiologist in the pre- and post-procedure evaluation and management services. Initial patient visits require that the physician be present to discuss the procedure with the patient and develop a treatment plan, but the NPP can obtain the patient’s medical history and other preliminary information that will lessen the radiologist’s time. In the hospital this is considered to be a “shared visit” that is billed at 100% of the MPFS under the physician’s NPI. In the office setting the services of the NPP may be considered “incident-to” the physician’s services and the entire encounter is also billed at 100% of the MPFS under the physician’s NPI. In addition, since the majority of IR procedures are assigned 0-day global codes, post-procedure visits can be handled by the NPP and be billed either at the 100% physician level if the incident-to rules are met, or at 85% of the MPFS if they are not.
Conclusion
When considering the addition of physician extenders to your practice, it is important to understand the differences among the various candidates. The practice should determine its goal for the addition of extenders – is it to increase physician efficiency, add a billable provider to the practice, or both? State licensing regulations and hospital credentialing rules will also shape the ultimate decision. Once on board, the physicians and NPPs will have to understand the rules for performing and documenting their individual involvement with the patient that will assure the practice is billing in compliance with Medicare regulations. Subscribe to this blog for the latest information.
Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.
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