June 30, 2010

ACR Radiology Coding Source™ May-June 2010

Registered Radiologist Assistant/Radiologist Practitioner Assistant

The following is an update to the questions and answers related to the responsibilities and training required of   registered radiologist assistants (RRAs) and radiology practitioner assistants (RPAs), and the impact of the Supervision Rule on their roles (initially published in the November/December 2006 ACR Radiology Coding Source).   If you have questions regarding this article, please contact the Economics and Health Policy department at (800)227-5463, ext 4132.

What are the roles of a registered radiologist assistant, radiology practitioner assistant, radiology practitioner extender and physician assistants?

The registered radiologist assistant (RRA), also known as a radiologist assistant, and radiology practitioner assistant (RPA) are registered radiological technologists who have undertaken a higher level of education and training. RRAs and RPAs are required to be supervised by a radiologist. They do not practice independently and do not interpret studies.  RPAs were previously represented by the National Society for the Radiology Practitioner Assistant (NSRPA), but now are representedby the Society of Radiology Physician Extenders (SRPE). 

Differences between RRAs and RPAs may have resulted, in some instances, from differences in educational standards, impacting the level of practice and overall autonomy of RRAs and RPAs in clinical practice. The RRA and RPA have substantially the same education and training and have in general the same skill sets.

The RPA acronym, however, has caused some confusion, since it sometimes has been incorrectly associated with the benefits and requirements of the physician assistant (PA) designation.  Some radiology practices hire PAs and train them to perform radiology services.  PAs differ from RRAs and RPAs in that PAs are qualified to receive a national physician identification number that allows them to bill separately for their services. A PA is trained in general medicine with little if any training in radiology, while an RPA’s training focuses on significant radiology training. PAs also are supervised by a physician within state-established limits. PAs may not function in a supervisory capacity; however, they may perform diagnostic tests under their own statutory benefits and state requirements for physician supervision. (Medicare Transmittal 1725)

How does the Supervision Rule apply to RRAs an RPAs?

Medicare's Supervision Rule does not allow RRAs or RPAs to perform studies that require personal supervision unless the supervising radiologist is physically present in the room.

Does the Supervision Rule apply to the technical component or to the professional component?

Medicare's Supervision Rule applies to the technical component of the diagnostic tests performed in both office (freestanding and independent diagnostic testing facility) and hospital settings. There are three levels of physician supervision required for diagnostic tests as outlined in Transmittal B-01-28:

General supervision: The procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the procedure. Under general supervision, the physician is responsible for training nonphysician personnel who perform diagnostic procedures and who are responsible for maintaining necessary equipment and supplies.

Direct supervision: The physician must be present in the office suite and immediately available to assist and direct throughout the procedure. This does not mean that the physician must be present in the room when the procedure is performed.

Personal supervision: A physician must be in the room during the performance of the procedure.

The Supervision Rule is a national policy set forth by the Centers for Medicare and Medicaid Services (CMS) and, thus, not at the discretion of the local carrier medical directors.

Click here for a copy of the CMS Medicare Physician Fee Schedule, which lists the current procedures and assigned supervision levels.

Are RRAs trained to perform studies that require personal supervision?  

Yes, RRAs receive education through an advanced academic program (baccalaureate or post-baccalaureate program) encompassing a nationally recognized radiologist assistant curriculum and a radiologist directed clinical preceptorship. There are a number of procedures in the RRA curriculum deemed to be appropriate for an RRA to perform under direct supervision, but currently defined by CMS as requiring personal supervision.

Is anything being done to change the ability to use RRAs and RPAs to perform procedures requiring personal supervision?

Yes, the ACR, American Society of Radiologic Technologists (ASRT), and the American Registry of the Radiologic Technologists (ARRT) are working with CMS to update the level of supervision required. These organizations have met with CMS several times to have the regulations changed. Until a change can be effected at the national level, radiology practices must not bill Medicare services when RRAs or RPAs perform studies that are not at the required level of supervision. That is, if personal supervision is required, it is fraudulent billing to submit the claim to Medicare if the study was performed by the RRA or RPA under direct or general supervision from the radiologist. 

Does the use of teleradiology meet the above participation requirements for a "personal" level of physician supervision?

No, teleradiology does not meet the requirements for "personal" supervision since, by definition, this level of supervision requires the physician to be present, physically, in the room.

Do only the radiological supervision and interpretation codes (RS&I) require personal supervision?

No, more than just the radiological supervision and interpretation codes require personal supervision, as noted in Medicare regulations. However, many codes requiring personal supervision are designated as RS&I codes. As mentioned above, go to the CMS Web site for a listing of the appropriate supervision levels currently assigned by Medicare.

When a radiological supervision and interpretation code is reported, the Medicare Claims Processing Manual, Chapter 13, Section 80.1, specifies that if the physician is not present for the supervision portion of an RS&I code, which requires personal supervision, the physician must append a -52 (reduced service modifier) to the professional component charge to show only an interpretation was provided.

Can an RRA or RPA interpret studies?

No, neither an RRA nor an RPA is trained, credentialed or licensed to interpret radiology studies, and the American College of Radiology, American Society of Radiologic Technologists, American Registry of Radiology Technologists and Society of Radiology Physician Extenders do not endorse interpretation of diagnostic images by RRAs or RPAs as part of their role. Only physicians should provide interpretations.

Does the Incident-To Rule Apply to RRAs and RPAs?

The incident-to rule does not apply to diagnostic tests. The incident-to rule covers non-hospital services when incidentally provided by supervised non-physicians as part of a medical service provided by the physician. The rule requires that there be an established physician relationship with the patient before a nonphysician can provide services collectively with a physician; therefore, most diagnostic and therapeutic procedures performed by radiologists are excluded. However, certain procedure-oriented radiology specialists (interventional radiologists, radiation oncologists, and breast imaging specialists) may be able to utilize this rule in certain instances when billing for procedures performed by an RRA or RPA.

Are there any other laws or pertinent regulations?

Yes, radiology practices need to carefully examine state statutes and regulations that control an RRA’s and RPA’s scope of practice.  Because the states regulate, through licensing, the practice scope, supervision requirements, and medical liability of nonphysician practitioners, the ACR advises that radiology practices consult with qualified local counsel for guidance on their state’s legislation and regulations.

Click here for a copy of the August 29, 2009 ACR, ARRT, and ASRT comment letter to CMS which provided additional information on the role of the RRA and RPA.


Physician Supervision Requirements in the Hospital Outpatient Setting 2009 (historical background)

Medicare Carriers Manual, Part 3, Claims ProcessTransmittal 1725, dated September 27, 2001.

Medicare Physician Fee Schedule (1/8/10), 2010 Supervision Levels click here.

Program Memorandum, Carriers (Transmittal B-01-28), dated April 19, 2001, Physician Supervision of Diagnostic Tests.