Four types of nonphysician professionals may be found in an imaging facility, assisting in or performing radiology services: physician assistants (PA), nurse practitioners (NP), registered radiologist assistants (RRA) and radiology practitioner assistants (RPA). The educational and training requirements are different for each of these professionals and therefore their corresponding scope of practice also varies.
PAs and NPs are frequently referred to as “nonphysician practitioners” and “mid-level providers.” RRAs and RPAs are frequently designated as physician “extenders.” For simplicity’s sake, in this discussion “extenders” will refer to all four designations while “nonphysician practitioners” will be limited to PAs and NPs.
PAs and NPs are health care professionals licensed to practice medicine with physician supervision within state-established limits. Although there are some state-specific variations, these professionals generally can perform physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care and write prescriptions. Services performed by PAs and NPs can be billed to Medicare under their own name and number; however, not all payers will credential these providers.
RRAs and RPAs are registered radiological technologists (RRTs) who have taken additional educational coursework and training. RPAs are sometimes incorrectly confused with PAs since both have the “PA” in their acronym. RRAs and RPAs are required to be supervised by a radiologist at all times. They are not trained, licensed and/or credentialed to interpret radiology studies. These designations are also heavily governed by individual state requirements that may limit their scope of practice.
Nonphysician practitioners may be able to perform and bill for services independent of a physician, depending on the Centers for Medicare and Medicaid Services (CMS) guidelines and state scope of practice statutes. The supervision requirements are found in the Medicare Benefit Policy Manual, Chapter 15, Section 80 and for diagnostic radiology services there are three levels: general, direct and personal. All interventional procedures are designated as “concept does not apply” since the services should be performed and billed by the rendering provider.
The supervision guidelines in the Medicare Benefit Policy Manual apply to all sites of service and are not limited to physician offices and IDTFs. The required level of supervision for a diagnostic test is that which is indicated in the Medicare Physician Fee Schedule (MPFS).
Beginning in 2019, CMS allows RRAs and RPAs the ability to perform diagnostic tests under direct supervision if permissible by state law and state scope of practice regulations.1 The majority of states have statutes or regulations that recognize RRAs/RPAs and the supervision guidelines in these states for directly performed services are general or direct supervision. CMS did note that they did not changing the level of physician supervision required for exams, nor create a new supervision indicator, but rather just changed the guidelines.
In response to COVID-19 and as part of the Public Health Emergency (PHE), CMS expanded telehealth services to be more broadly accepted and applicable than the system was prior to the pandemic. CMS, for the duration of the PHE, has redefined direct supervision under MPFS to be provided through interactive real-time audio-video telecommunication technology. This may have a significant impact on radiology services where direct supervision can be performed via real time technology. This allows the physician to provide real-time assistance and direction throughout a procedure or service by allowing them to see and interact with the staff member and patient without adding any unnecessary exposure. It is important to note, the supervision adjustments are meant as a minimum requirement. There may be circumstances in which the physical presence of the physician with the patient in the same location is necessary and more appropriate, for example administration of certain drugs or therapies.
CMS has finalized to extend direct supervision expansion under MPFS to end later in the calendar year in which the PHE ends or December 31, 2021. This will allow, along with other waivers and extensions, an easement to the change in supervision than immediate pending the end of the PHE and for physicians and practices to prepare for the change back to the in-person requirement
The MPFS final rule makes permanent several workforce flexibilities provided during the COVID-19 PHE that allow non-physician practitioners to provide the care they were trained and licensed to give, without imposing additional restrictions by the Medicare program. Specifically, CMS finalized that non-physician practitioners such as nurse practitioners and physician assistants can supervise the performance of diagnostic tests within their scope of practice and state law, as long as they maintain required statutory relationships with supervising or collaborating physicians. CMS also finalized that diagnostic tests performed by a PA in accordance with their scope of practice and state law do not require the specified level of supervision assigned to individual tests, because the relationship of PAs with physicians would continue to apply.
Melody Mulaik, CRA, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle Coding Strategies.