Nonphysician extenders can boost productivity

November 2, 2009

With radiologists already working at record productivity levels, there is not much room left to maintain income levels by working harder.

With radiologists already working at record productivity levels, there is not much room left to maintain income levels by working harder. Many radiology practices are now considering the use of nonphysician providers to gain efficiencies in their radiology departments. There can be significant benefits to the use of these individuals; they can perform many tasks with limited supervision, which, in turn, frees up the radiologist to become more productive. Many of these providers move easily from other specialty areas, like surgical or primary care practices, into interventional radiology. In other cases, the nonphysician providers have worked with radiologists or were radiologic technologists before they obtained additional training.

Groups thinking of hiring such providers should carefully weigh differences in the training and experience of potential employees and consider the reimbursement ramifications. The radiology practice needs must be matched to the hiree’s education and experience. Also, rules on reimbursement differ depending on how the nonphysician provider is trained and licensed and states may restrict which functions they can perform. Some practices plan to be reimbursed for the services of nonphysician providers while other practices may view an increase in radiologist productivity as adequate return on investment.

There are five categories of nonphysician providers that apply to the specialty of radiology: nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), radiology assistant (RA), and radiology practitioner assistant (RPA). Each has an educational background designed to prepare the degree- or certificate-holder for a unique role in healthcare.

NPs are registered nurses who have completed advanced nursing education, usually a master’s degree, and training in the diagnosis and management of common medical conditions, including chronic illnesses.

CNSs are advanced practice nurses, usually with a master of science degree in nursing. These professionals do not typically have a radiology background. However, their training and experience do apply to interventional radiology, specifically to performing noncomplex procedures, obtaining preexam histories and physicals, and providing postexam evaluation and management services.

PAs are broadly educated as medical providers and are regulated in all states, typically by medical boards. Educated as medical generalists, they can work with physicians in virtually any specialty, including radiology and its subspecialties. Some of the common responsibilities of a PA in radiology include obtaining patient histories and performing physical examinations, carrying out fluoroscopic tests and procedures and needle biopsies, inserting and removing central and peripheral venous catheters, and performing pre- and postprocedure evaluations and postprocedure follow-up. PAs may administer conscious sedation and they commonly provide first-assist services in the procedure room. They often serve as a point of contact between referring physicians and the radiologist. Because the supervising physician delegates responsibilities to the physician assistant, the PA’s role can flex to fit the needs of the radiology practice.

The primary differences be-tween the RA and RPA are philosophical and educational, leading to a difference in overall independence and autonomy in clinical practice.

The RPA is a professional similar to a nurse practitioner, but with a concentration in radiology. The RPA will be hired primarily by radiology groups with a private practice and will have more independence in performing procedures within the primary healthcare facility and in satellite clinics or hospital, thus will be a true physician extender to the radiologist. The radiologist reviews and signs off all work performed by the RPA.

The RA will fill a role in an advanced-level practice as technical staff employed by the facility, primarily in medical centers and large teaching hospitals, and will be limited in the type of procedures he or she can perform.


Another big distinction is how the different nonphysician provider classifications are reimbursed by payers. PAs, CNSs, and NPs, but not RAs and RPAs, are recognized providers for purposes of Medicare and insurance reimbursement. The work of RAs and RPAs is covered as part of the professional or global fees, or “incident to” the physician’s services.

Prior to Jan. 1, 1998, direct billing and payment for NP, CNS, and PA services to hospital inpatients and outpatients was available only under limited circumstances. Then Section 4511(a)(2)(B) of the Balanced Budget Act of 1997 amended §1861(b)(4) of the Social Security Act to exclude the professional services of NPs, CNSs, and PAs from hospital services.

Accordingly, NPs and CNSs became authorized to bill CMS directly for professional services furnished to hospital patients. Direct billing of and payment for these professional services must be made to the NP or CNS. However, if the NP or CNS reassigns payment for his or her professional services to hospital patients to the hospital or other employer, payment can be made for these services at 85% of the Medicare physician fee schedule.

PAs cannot bill CMS directly for their professional services. The employer of a PA must bill for that employee’s professional services when furnished to hospital patients and payment is always made to the PA’s employer or contractor at 85% of the Medicare physician fee schedule. Since PAs cannot bill the program directly, they do not have the option to reassign payment for their professional services to their employer or contractor.

All 50 states cover medical services provided by CNSs, NPs, and PAs under their Medicaid programs. The rate of reimbursement, which is paid to the employing practice, is either the same as or slightly lower than that paid to physicians. Private insurers generally cover medical services provided by NPs, CNSs, and PAs based on Medicare coverage rules.

Nonphysician providers can have a positive impact on a radiology practice. If the current trend continues, the years to come will see a greater use of nonphysician providers-with a more focused educational background-in radiology.