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