For Radiology Assistants: To Bill or Not to Bill?

Radiologist assistants (RAs) and radiology practitioner assistants (RPAs) may be highly educated and experienced, but CMS won’t pay for their services in all settings. Reimbursement depends on the setting (office, hospital inpatient or outpatient, and independent diagnostic testing facility), the level of physician supervision, and the type of procedure (diagnostic versus surgical/interventional).

Thomas W. Greeson and Paul Pitts, attorneys with Reed Smith, LLP in Falls Church, Va. and San Francisco, respectively, fill in the details about CMS requirements for RA/RPA reimbursement and recent changes by CMS, in an article just published in the Journal of the American College of Radiology.

One of the problems with attaining reimbursement is that RAs and RPAs don’t have their own Medicare benefit category, though nurse practitioners and physician assistants do. The radiology extenders have to bill for their services under the provider, if they can bill at all.

Greeson and Pitts noted in the article that the radiology extenders may be providing services properly under state law, but that doesn’t mean they’re permitted under Medicare reimbursement rules. Plus, third party payers have their own rules, which might be more permissive. CMS’s tight leash on the RAs and RPAs means that hospitals, including outpatient clinics, cannot as easily reduce costs by using RA extenders instead of physicians.

In January 2010, CMS revised its rules on supervision of RAs for hospital outpatient diagnostic testing. The new regulations standardized the physician supervision requirements, and also made the requirements uniform across service settings.

In 2011, after considering public comments, CMS adopted an additional change: altering the definition of “direct supervision.” This rule now states that for outpatient diagnostic services at a hospital, direct supervision means the supervising physician has to be “immediately available,” which does not mean the physician needs to be at a particular part of the hospital campus.

The authors noted that in the hospital setting, Medicare does not reimburse separately for non-diagnostic services (surgical or invasive procedures) performed by an RA or RPA, even if a radiologist supervised. Instead, the hospital is paid by Medicare for any auxiliary services as part the hospital prospective payment system. The radiologist can bill for services performed only by the physician; billing for the RA’s services under the physician’s number would be considered fraud.

Co-author Greeson, a past general counsel of the American College of Radiology who specializes in healthcare regulatory issues involving radiologists, said there is a widespread misperception and misconception about what radiology assistants are permitted by CMS to do in order to qualify for reimbursement.

Greeson recommended that any radiology group that employs an RA or RPA, and uses them in the hospital setting, should carefully look at how they’re billing.

“If one has billed for services they should not have billed for, that’s technically an overpayment and they have an obligation under the law to return those payments,” Greeson said.

He noted that CMS is stepping up their auditing practice. “Every radiology group is well served to look at their own compliance before the Medicare auditor comes knocking on their door.”

The bottom line for physicians, he said, is “if they’re performing services in a hospital setting, they need to understand the rules.”