Position Statement: The Role of Physician Assistants in ...


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  1. 1. Standards of Practice Position Statement: The Role of Physician Assistants in Interventional Radiology Stefanie M. Rosenberg, MS, PA-C, David A. Rosenthal, MHP, PA-C, Dheeraj K. Rajan, MD, Steven F. Millward, MD, Richard A. Baum, MD, James E. Silberzweig, MD, Catherine M. Tuite, MD, and John F. Cardella, MD; with the American Academy of Physician Assistants J Vasc Interv Radiol 2008; 19:1685–1689 Abbreviations: IR interventional radiology, NP nurse practitioner, PA physician assistant, RA radiologist assistant, RPA radiology practitioner as- sistant DURING the past decade, interven- tients before and after procedures. It is tice. Federally employed PAs must tional radiology (IR) has been trans- clear that the recruitment of additional meet the first two criteria, but need not formed from a referral-based to a clin- clinical support staff into the “IR be licensed. PAs are eligible to obtain ically based subspecialty. This has team” is needed (1–3). their own Drug Enforcement Admin- resulted in a fundamentally different Today, modern IR divisions resem- istration number for prescription writ- type of workload for the practicing in- ble surgical subspecialties, providing ing (11,12) and their own National terventional radiologist. During this the full spectrum of clinical care. Pa- Provider Identification number (as de- same time period, the scope of proce- tients are seen in ambulatory clinics scribed later in the billing options for dures provided by interventional radi- before and after procedures and on PAs). PAs on the medical staffs of hos- ologists continued to expand. A result admitting and consultation services pitals are subject to similar credential- of this decade of robust growth is a while in the hospital. Although the ing requirements as physicians. Their shortage of properly trained and qual- care we provide to patients is similar responsibilities must conform to insti- ified professionals. We now face a di- to that in other clinical services, the tutional policy and state regulations. lemma in not only how to keep up personnel we utilize to provide this State and hospital requirements vary with procedural demand, but also care is not (4,5). in terms of prescriptive authority, use how to provide clinical care for pa- The most frequently used physician of ionizing radiation, level of physi- extenders are physician assistants cian supervision, and credentialing. (PAs), nurse practitioners (NPs), radi- More information regarding state laws ology practitioner assistants (RPAs), governing PAs is available on the From the Department of Radiology (S.M.R.), Lu- theran General Hospital, Park Ridge, Illinois; Divi- and radiologist assistants (RAs). Each American Academy of Physician As- sion of Angiography and Interventional Radiology has different training, background, sistants Web site (13). (D.A.R., R.A.B.), Brigham and Women’s Hospital, qualifications, and scope of practice, Boston; Department of Radiology (J.F.C.), Baystate and not all can bill for their services Health System, Springfield, Massachusetts; Division of Vascular and Interventional Radiology, Depart- (Appendix). To make matters even BILLING/CODING ment of Medical Imaging (D.K.R.), University of more complex, these differences are Employers of PAs are eligible for Western Ontario, London, and Peterborough Re- state-, provider-, and hospital-specific. gional Health Centre, Peterborough, Ontario, Can- reimbursement from Medicare for It is therefore critical to understand ada (S.F.M.); Department of Radiology (J.E.S.), St. physician services provided by PAs these differences before deciding to Luke’s–Roosevelt Hospital Center, New York, working with the supervision of a New York; and Department of Radiology, Divi- hire a physician extender (6 –10). This physician. Fees generated by PAs may sion of Interventional Radiology (C.M.T.), Univer- position statement will delineate the sity of Pennsylvania Medical Center, Philadelphia, partly offset or completely cover the potential roles of PAs in an IR practice. Pennsylvania. Received August 7, 2008; final revi- cost of their employment (5,14,15). sion received August 29, 2008; accepted Septem- PAs should obtain their own National ber 4, 2008. Address correspondence to S.M.R., De- REGULATIONS Provider Identification number for partment of Radiology, Lutheran General Hospital, 1775 Dempster St., Park Ridge, IL 60068; E-mail: Medicare billing. stefanier@comcast.net PAs must graduate from a nation- Under Medicare, PA services are ally accredited PA educational pro- reimbursed at 85%–100% of the physi- None of the authors have identified a conflict of interest. gram, pass the national certification cian fee. “Incident to” billing allows examination administered by the Na- physicians to bill at 100% in the out- © SIR, 2008 tional Commission on Certification of patient office or clinic setting provided DOI: 10.1016/j.jvir.2008.09.004 PAs, and obtain a state license to prac- certain physician involvement and in- 1685
  2. 2. 1686 • Position Statement on the Role of Physician Assistants in IR December 2008 JVIR Table 1 Medicare Policy Chart for Physician Supervision Setting Requirement Reimbursement Rate Services Office/clinic when State law 85% of physician’s fee schedule All services PA is legally authorized physician is not on toprovide that would have been site covered if provided personally by a physician Office/clinic when Physician must be in 100% of physician’s fee schedule* Same as above physician is on site the suite of offices Home visit/ house State law 85% of physician’s fee schedule Same as above Skilled nursing facility/ State law 85% of physician’s fee schedule Same as above nursing facility Hospital State law 85% of physician’s fee schedule Same as above First assisting at State law 85% of physician’s first assist fee Same as above surgery in all settings schedule† Federally certified rural State law Cost-based reimbursement Same as above health clinics HMO State law Reimbursement is on capitation basis All services contracted for as part of an HMO contract * Using carrier guidelines for “incident to” services. † For example, 85% 16% 13.6% of surgeon’s fee. creased supervision criteria are met. tity to share visits made to patients the deemed within the PA’s scope of prac- “Incident to” billing is not applicable same day with the combined work of tice to the supervising physician and in the inpatient setting. both billed under the physician at the credentialing committees of indi- Billing for inpatient services differs 100% of the fee schedule. That is, if the vidual hospitals. States define the from billing for services in an outpa- PA provides the majority of the ser- broad, overall practice of PAs and may tient office or clinic. In hospitals, if the vice for the patient and the physician regulate some specific areas, such as supervising physician and the PA provides any face-to-face portion of PA use of ionizing radiation, narcotic treat a patient on the same day, ser- the Evaluation and Management en- schedules allowed within a PA’s pre- vices can be billed at 100% of the counter, the entire service may be scriptive authority, and the responsi- Medicare fee schedule if Medicare’s billed under the physician. This new bilities of the supervising physician. shared billing requirements are met, rule does not extend to procedures or (The AAPA Web site [13] describes whereas it is 85% if the service is per- consultations. If the physician does each state’s requirements.) formed by the PA with no direct phy- not provide some face-to-face por- In addition to the broad scope of sician involvement. Private insurers tion of the Evaluation and Manage- practice for PAs defined by state law generally cover services provided by ment encounter, the service is appro- and regulations (or federal agency PAs. Those services are billed under priately billed at the full fee schedule guidelines for federal employees), the the physician’s name or the PA’s name amount under the PA’s National scope of practice for an individual PA depending on the particular payer’s Provider Identification number with also is determined by delegation from policy (16,17). reimbursement paid at the 85% rate the supervising physician and by the More regulatory information on re- (18) (Table 1). hospital privileging process. Hospital imbursement of PA, NP, and RPA ser- credentialing of PAs is similar to that vices can be found on the Web sites of MEDICAID COVERAGE of physicians. PAs must apply for the American Academy of PAs (www. privileges and submit to the same aapa.org/gandp/3rdparty.html), American Presently, all 50 states cover medi- types of background checks as physi- Academy of NPs (www.aanp.org), and cal services provided by PAs under cians. As a rule, hospitals will grant Certification Board for RPAs (www. their Medicaid fee-for-service or man- PAs only privileges that the supervis- cbrpa.org/pdf/CBRPA_medicare_guide. aged care programs. The rate of reim- ing physician also holds. Some hospi- pdf), respectively. bursement, which is paid to the PA’s tals grant PA privileges based on the As of October 25, 2002, the Centers employer, is the same or slightly lower request of the supervising physician, for Medicare and Medicaid Services than that paid to physicians (19). who is responsible for the PA’s perfor- issued new rules providing PAs and mance. Others require documentation their physicians increased latitude in SCOPE OF PRACTICE of competency via physician supervi- hospital and office billing for Evalua- sion of a specified number of each pro- tion and Management services. The As previously discussed, the scope cedure before the PA is allowed to per- new requirement (Medicare Transmit- of practice for a PA will vary from form them without the physician tal 1776) will allow PAs and physicians state to state. Most states leave the de- present. who work for the same employer/en- termination of specific procedures Before hiring a PA into a practice, it
  3. 3. Volume 19 Number 12 Rosenberg et al • 1687 is prudent for the supervising radiol- Table 2 ogist to contact the credentialing com- Procedures/Responsibilities that May Be Delegated to PAs mittees to determine if there are re- strictions that would be relevant to the History and physicals scope of practice of the position being Rounds/inpatient and outpatient evaluation and management services considered. This is especially impor- Requesting consultations from other medical services tant if more than one hospital is cov- Ordering of laboratory tests and imaging studies Manage medical/surgical emergencies and initiate appropriate therapies until arrival ered by the radiologists, as there can of physician be policy differences among hospitals. Communicating with referring services The type of procedures covered by Established patient follow-up/evaluation and management billing the interventional group will directly Clinic visits/management define the scope of practice for a PA. Write prescriptions Within that group, procedures as- Admissions/discharges signed to the PA will be based on phy- Patient education sician assessment of the PA’s ability to Resident teaching perform those cases safely, as well as Obtaining informed consent First-assisting on procedures the PA’s confidence in his or her own Prescribe conscious sedation (varies by state) ability to do so. As the PA becomes Wound care more experienced with procedures Suturing dislodged catheter and the imaging modalities used to Vascular access guide them, they can be trained to Peripherally inserted central catheters safely perform more complex cases. Central venous port placement, removal, and revision Keeping detailed documentation of Nontunneled central venous catheter placement the specialized training can help to al- Tunneled central venous catheter placement, exchange, and removal leviate any medical staff/credential- Biopsies ing committee concerns and address Drainages Abscess any objections that may arise from Empyema others who believe they should be Seroma granted similar privileges. Chest tube placement Finally, it is the recommendation of Tunneled chest tubes for drainage of pleural effusions the Society of Interventional Radiol- Tunneled peritoneal catheters for ascites drainage ogy (SIR) that, regardless if state and Thoracentesis local hospital regulations have been Paracentesis met, the PA performs procedures in- Baker cyst aspiration dependently only after the radiologist Drain exchange/removal Vein sclerotherapy and the PA are confident the proce- Ambulatory phlebectomy dures can be done safely and with Hysterosalpingography high quality. In addition, SIR recom- Lumbar puncture mends that, even after the PA is per- forming procedures independently, the radiologist remains available for immediate consultation should the PA encounter procedural difficulties or propriate for midlevel practitioners. In ated PA postgraduate programs in spe- adverse situations. most cases, this training will occur in cialties such as surgery, orthopedics, A survey of PAs attending the SIR IR departments or sections. Although obstetrics and gynecology, emergency 2005 Annual Meeting produced a list students may not achieve competency medicine, psychiatry, and medical on- of commonly performed procedures in IR procedures, this exposure to IR cology in which PAs train in a fashion (Table 2). This list was obtained from while in training will provide a foun- similar to resident physicians in that a sample of PAs from across the coun- dation for further training and result specialty (20). Development of PA post- try, but may not include every proce- in an increased awareness of the spe- graduate programs in IR in conjunction dure that is in a PA’s scope of practice cialty among PA graduates. with interventional radiologists is desir- and may be more extensive than in PA graduates seeking additional able. This training should be standard- some practices. training in IR currently receive that ized in terms of procedural, clinical, and training from the IR physicians who su- didactic content. pervise them. This training allows PAs EDUCATION AND TRAINING to develop proper procedural and clini- cal skills that are in concordance with QUALITY ASSURANCE To increase the number of PAs in IR, SIR recommends that an IR rota- the standards expected by the practice Whether the PA who has been hired tion be included in PA educational or hospital for which they work. There by a radiology practice is new to IR or programs. PA students should be ex- are no formal postgraduate training experienced, monitoring of outcomes posed to and receive training in pro- programs for PAs in IR. Various univer- and complications should be docu- cedural and clinical aspects of IR ap- sities and medical institutions have cre- mented. This tracking can be accom-
  4. 4. 1688 • Position Statement on the Role of Physician Assistants in IR December 2008 JVIR plished through programs such as Hi- Because the use of PAs in IR is their areas of competency, and with IQ. Easily accessible documentation of fairly new, there are few studies doc- appropriate training and supervision, this monitoring will be critical should a umenting efficacy of this practice (14). these practitioners may provide med- serious complication or adverse event Studies in other specialties have vali- ical care similar in quality to that of occur. Some hospitals may also require dated the positive impact of the PA’s physicians at less cost.” In addition, an documentation of continual monitoring contributions. Miller et al (5) reported American Medical Association survey for privilege renewal. It is strongly sug- on the use of PAs in a trauma center of approximately 4,000 solo-physician gested that performance reviews be pro- with the following benefits: decrease practices (23) found that employing vided semiannually or quarterly, espe- in length of stay in critical care units, PAs improved productivity. A recent cially in the first 2 years of employment. increase in quality of care, and im- study by a health care research firm Most institutions require an annual per- provement in resource utilization. Fur- (24) found increased patient satisfac- formance review, but more frequent re- ther noted was that the cost of hiring tion when they are scheduled to see a views of the PA’s performance can as- the PAs was significantly offset by the PA in the office versus other health sist in identifying areas of strength as reimbursement fees generated (5). care professionals. well as those needing further train- Thourani and Miller (4) detailed their ing. Such meticulous documentation 30-year experience with PAs in cardio- also assures hospital administrators thoracic surgery and concluded that CONCLUSION and medical staff that appropriate the usefulness of PAs cannot be over- training and monitoring are always estimated. They were skilled first as- SIR supports the utilization of PAs being provided. sistants, provided consistent patient in IR practice. PAs have a proven management, and enabled expansion record of providing high-quality, cost- of services (4). effective care, which serves to enhance COST EFFECTIVENESS, patient satisfaction and the productiv- PATIENT SATISFACTION, A national survey conducted by Opinion Research Corporation and ity of the practice they serve. As li- AND EXCELLENCE IN censed health care professionals with PRACTICE presented to the American Academy of Physician Assistants in May 2007 appropriate training, PAs can perform There are currently more than 68,000 (21) showed a high awareness of, and a majority of the minor procedures in PAs in clinical practice within the strong positive feelings toward, the an IR practice, allowing the physicians United States. They work in virtually PA profession. A majority of the pub- the freedom to concentrate on more every medical and surgical specialty lic said they are willing to be treated difficult and complex cases, as well as and subspecialty. There are 139 ac- by PAs (21). A 1994 report by a federal increasing the volume of cases per- credited PA programs, which pro- Advisory Group on Physician Assis- formed. PAs are invaluable as first- duced approximately 4,600 new grad- tants in the Workforce (15) similarly contact consultants for referring ser- uates in 2006. PAs can prescribe found consistently high levels of pa- vices, greatly enhance continuity and medication in all 50 states, Guam, and tient acceptance and satisfaction. quality of care, and facilitate the sched- the District of Columbia. Radiology Studies show that PAs practicing as uling of cases. PA education, training, practices that have hired experienced part of a supervising physician’s team credentialing, team approach, and abil- PAs have found that they bring many provide high-quality health care. A ity to bill for services may afford po- useful skills that enhance the overall 1994 federal study of state practice en- tential significant advantages for operation of an IR service (15). vironments (22) reported, “[w]ithin many IR practices. APPENDIX: COMPARISON OF PAs, NPs, RPAs, AND RAs Order tests, write Physician prescriptions, DEA/NPI Services Perform Extender Education/Degree Certification Licensed make diagnoses No. Reimbursed Procedures PA Broad-based general NCCPA (national Yes Yes Yes Yes Yes medicine/physician examination, model/BS or MS required in all states); recertification every 6 years, 100 h CME/2 y NP General medicine/MS AANP/ANCC Yes Yes Yes Yes Yes RA Radiology/BA, MS ARRT (10 states) In some states No No No Yes RPA Radiology/BA CBRPA (3 states) No (have RT No No No Yes license) Note.—AANP American Academy of Nurse Practitioners; ANCC American Nurses Credentialing Center; ARRT American Registry of Radiologic Technologists; CBRPA Certification Board for Radiology Practitioner Assistants; CME Continuing Medical Education; DEA Drug Enforcement Administration; NCCPA National Commission on Certification of Physician Assistants; NPI National Provider Identification.
  5. 5. Volume 19 Number 12 Rosenberg et al • 1689 References 9. American Academy of Physician As- 17. American Academy of Physician Assis- 1. Brown DB, Gould JE. Building in in- sistants. Physician assistants and tants. Reimbursement hospital billing. terventional oncology. Tech Vasc In- radiology practitioner assistants: the Available at http://www.aapa.org/ terv Radiol 2006; 9:90 –95. distinction. Available at http://www. gandp/sharedbilling.html. Accessed Oc- 2. Goldberg SN, Bonn J, Dodd G, et al. aapa.org/gandp/rpas. Accessed Octo- tober 29, 2007. Society of Interventional Radiology In- ber 19, 2007. 18. Wiskerchen S. Billing basics for phy- terventional Oncology Task Force. In- 10. American Academy of Nurse Practitio- sician assistants and nurse practitio- terventional oncology research vision ners. Nurse practitioners as an ad- ners. J Med Pract Manage 2004; 1:175– statement and critical assessment of the vanced practice nurse: role position 178. state of research affairs. J Vasc Interv statement. Available at http://www. 19. American Academy of Physician Assis- Radiol 2005; 16:1287–1294. npfinder.com/faq.pdf. Accessed Octo- tants. Third party reimbursement for 3. Hong K, Georgiades CS, Hebert J, et al. ber 19, 2007. physician assistants. Available at http:// Incorporating physician assistants and 11. American Academy of Physician Assis- www.aapa.org/gandp/3rdparty.html. physician extenders in the contempo- tants. DEA brief. Available at http:// Accessed October 29, 2007. rary interventional oncology practice. www.aapa.org/gandp/issuebrief/ 20. Association of Postgraduate Physician Tech Vasc Interv Radiol 2006; 9:96 –100. DEA.htm. Accessed October 19, 2007. Assistant Programs. Available at http:// 4. Thourani VH, Miller JI. Physician as- 12. American Academy of Physician Assis- www.appap.org/prog_specialty.html. sistants in cardiothoracic surgery: a 30 tants. Prescribing authority. Avail- Accessed October 19, 2007. year experience at a university center. able at http://www.aapa.org/gandp/ 21. American Academy of Physician Assis- Ann Thorac Surg 2006; 81:195–199. rxchart.html. Accessed October 29, tants. Majority of public say they are 5. Miller W, Riehl E, Napier M, Barber K, 2007. willing to be treated by PAs. Available Dabideen H. Use of physician assis- tants as surgery/trauma house staff at 13. American Academy of Physician Assis- at http://www.aapa.org/majoritysays. an American college of surgeons veri- tants. Regulatory authorities. Available html. Accessed October 19, 2007. fied level II trauma center. J Trauma at http://www.aapa.org/gandp/state- 22. Sekscenski ES, Sansom S, Bazell C, 1998; 44:372–376. law-summaries.html. Accessed October Salmon ME, Mullen F. State practice 6. Strickland G. Physician extenders: 29, 2007. environments and the supply of physi- which one is right for you? Appl Ra- 14. Stecker MS, Armenoff D, Johnson MS. cian assistants, nurse practitioners, and diol 2005; 8:23–28. Physician assistants in interventional certified nurse midwives. N Engl 7. Ellenbogen PH, Hoffman TR, Short, radiology. J Vasc Interv Radiol 2004; J Med 2004; 331:1266 –1271. BW, Gonzalez A. The RA: what the 15:221–227. 23. Wozniak GD. Physician utilization of radiologist needs to know. J Am Coll 15. American Academy of Physician Assis- non-physician practitioners: socioeco- Radiol 2007; 4:461– 470. tants. Physician assistants in radiology. nomic characteristics of medical practice. 8. American Academy of Physician Assis- Available at http://www.aapa.org/ Chicago: American Medical Association tants. Physician assistants and radiol- gandp/radiology.html. Accessed Octo- Center for Health Policy Research, April ogy practitioner assistants: guide to new ber 19, 2007. 1995. hires. Available at http://www.aapa. 16. Portman RM. The use of physician 24. Doscher C. Visits with PAs have org/gandp/paempguide.pdf. Accessed extenders in radiology. Interv Radiol shorter wait times. AAPA News 2007, October 19, 2007. News 2003; 16:3– 6. 28:1.