Radiology Assistants: A User’s Guide

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From May 2007 to January 2008, an Atlanta, Georgia-based radiologist signed and submitted thousands of reports in his name, with one major caveat—he didn’t review a single one. Instead, he delegated the work to his radiology practitioner assistants (RPAs), who interpreted the exams and prepared the reports. In November 2009, the US Department of Justice caught on and indicted him under federal charges of wire fraud, mail fraud, health-care fraud, and obstruction of justice.
“There is virtually no potential for reimbursement for an RPA’s or radiologist assistant’s (RA’s) independent provision of professional interpretations of radiographs, even if he or she is working under the supervision of a physician in a hospital setting. Likewise, private payors, in most instances, are not reimbursing for RPAs’ or RAs’ independent provision of professional services, but should be consulted for billing guidance.” —Lisa Brian, vice president of operations, West Division, Medical Management Professionals Inc, Atlanta, Georgia
imageLisa Brian
Although this particular case is severe, Brian says that many practices simply fall prey to misinformation. “I believe there is a misconception out there that if a physician is employing an RA or RPA, he or she can bill for the RA’s or RPA’s interpretation of radiographs,” Brian says, “but you can’t.” In her recent white paper, “Radiology Assistants Provide Important Skills, but Misconceptions Can Put Practices at Risk,” Brian reports on the confusion behind RPAs’ permitted duties, as well as the widespread uncertainty about available reimbursement mechanisms for RAs’ services. “Groups considering incorporating RAs should therefore familiarize themselves with the appropriate role of the RA, existing payment rules with applicable payors, state licensure requirements, and potential liability issues that emerge with RA utilization,” she writes. Rise of the Supertechs RPAs first emerged in the 1990s, when the US Department of Defense asked Weber State University in Utah to address the shortage of radiologists in the armed forces’ medical program. The resulting RPA program, still in effect today, is the predecessor of the 7 to 10 existing programs for RAs. In 2003, the ACR® and American Society of Radiologic Technologists issued a joint statement that formally recognized RAs and delineated their roles. The ACR identifies an RA as a radiographer, certified by the American Registry of Radiologic Technologists (ARRT), who has graduated from an advanced academic program that offers a nationally recognized radiologist-assistant curriculum and a radiologist-directed clinical preceptorship (see table). According to a 2007 article in the Journal of the American College of Radiology: JACR, the Certification Board for Radiology Practitioner Assistants states, “RPAs can perform all fluoroscopic procedures, static and dynamic; evaluate imaging procedures to determine normal from abnormal and provide radiologists with technical reports; and perform invasive procedures.”1 While “the scope of practice for RPAs includes language that presumes that their scope is not limited and may be determined under the discretion of physicians,” RAs have a more “specific and constricting” function that requires “a higher level of supervision,” the article1 continues. In her paper, Brian writes that 11 states—Arkansas, Florida, Iowa, Mississippi, Montana, New Mexico, New York, Oregon, Tennessee, West Virginia, and Wyoming—have drafted legislation that certifies RAs and discusses their scope of practice. Language in the provisions varies from state to state; therefore, Brian says, practices should contact the appropriate agency or accreditation board to determine the exact regulations that exist. Clearing Up the Confusion According to Brian, practices run into trouble when they attempt to bill federal, state, or commercial payors for an RA service independently. Despite information received from mistakenly informed academic RA programs, RAs are not considered midlevel physician extenders or nonphysician practitioners by Medicare. Unlike physician assistants (PAs) and certified nurse practitioners, RPAs and RAs do not currently qualify for independent billing authority under Medicare and do not possess Medicare billing provider numbers. “As a result, there is virtually no potential for reimbursement for an RPA’s or RA's independent provision of professional interpretations of radiographs, even if he or she is working under the supervision of a physician in a hospital setting,” Brian explains. “Likewise, private payors, in most instances, are not reimbursing for RPA’s or RA's independent provision of professional services, but should be consulted for billing guidance.” Brian suggests that the source of the uncertainty might be the similar sound of the PA designation, which is recognized by CMS, has a national provider identifier, and therefore has a mechanism to capture reimbursement. Physicians might be inclined to equate a PA with an RPA or RA. If radiology practices code an RPA’s or RA's provision of professional services independently from the supervising physician, however, they might face audits and fines for violating the federal False Claims Act. Another important fact to which Brian calls attention is that RPAs and RAs cannot replace the physician. “Rather than use the RA as an extender to the practice, some practices think they can use RAs almost in lieu of a physician,” Brian explains, recalling the Atlanta incident. To limit potential liability, practices must be aware that RAs should be hired for productivity purposes, Brian says, adding that RAs can free up physicians to concentrate on reimbursable activities. “They can help gain efficiencies if a physician group uses them appropriately,” Brian says. “They can assist with certain parts of the practice to help the radiologist maximize time reading films and performing interpretations.” For example, RAs can carry out preprocedural and postprocedural tasks, such as getting patient-consent forms and collecting extensive clinical histories. RAs can also assist radiologists with intensive interventional-radiology procedures that might require two sets of hands. In addition, they may pass on the supervising radiologist’s findings to a referring physician, as well as helping with triage and scheduling emergency cases. “They can determine how to move schedules around so it makes the radiologist more efficient,” Brian continues. “It just helps speed up the turnover of patients and helps with organization.” Best Practices Brian reports that the development of reimbursement mechanisms for RAs is not likely in the immediate future. This lack of federal reimbursement has caused some groups that were initially interested in hiring RAs to back off, she says says. Still, many practices recognize RAs’ efficiency factor and are joining in the hiring trend. Before employing an RA, the ACR recommends that radiologists make sure that the individual is licensed in the state in which they wish to practice and verify that he or she is in good legal standing. Furthermore, physicians should consult hospital policies, as well as their hospital contracts for radiology services, to check the language in the agreements. Some might dictate the way in which a supervising radiologist can interact with an RA, while others might prevent practices from hiring RAs in the first place. “It would be wise to check the information of the ACR and ASRT (among others) consistently, as the RA profession is evolving, and the clinical and reimbursement environment may easily change in the near future,” Brian advises. “By taking these steps, radiology groups can increase the likelihood that the RA will become an important and valuable asset to the practice.” RA Roles and Responsibilities2 Under radiologist supervision, the radiologist assistant performs patient assessment, patient management, and selected exams, including:
  • obtaining consent for, and injecting, agents that facilitate and/or enable diagnostic imaging;
  • obtaining clinical history from the patient or medical record;
  • performing preprocedure and postprocedure evaluation of patients undergoing invasive procedures;
  • assisting radiologists with invasive procedures;
  • performing fluoroscopy for noninvasive procedures, with the radiologist providing direct supervision of the service;
  • monitoring and tailoring selected exams under direct supervision;
  • communicating the report of the radiologist’s findings to the referring physician, or an appropriate representative, with appropriate documentation;
  • providing nasoenteric and oroenteric feeding-tube placement in uncomplicated cases; and
  • performing selected peripheral venous diagnostic procedures.
Elaine Sanchez is a contributing writer for ImagingBiz.com.