The author thanks Chris Davis, PA-C RT, and Anne Marie McLellan, DO, for their assistance with this article.
Overview
Over the last 20 years, IR has seen an increase in the hiring of advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs); the term "midlevel" is no longer used. IRs are recognizing such benefits as increasing revenue, throughput, billing and interface of APPs with providers/patients. APPs often become the face of IR in the facility. They increase the turnaround times in the IR suite. APPs become an integral part of the IR team.
While the physician is in difficult or complex procedures, the APP can deal with minor procedures such as thoracentesis, paracentesis, ports, dialysis catheters and nephrostomy tube changes, among others. APPs can also round on inpatients, consults and follow-ups.
They write pre- and post-op orders and can put out fires, deal with phone calls and intercept complications. More than 90 percent of these procedures are billable, and there are evaluation and management (E&M) codes for phone calls.
One disadvantage is that APPs can bill at only 85 percent of what the physician bills, but that lower level is offset by the increased volume of completed procedures. That is revenue generated that might otherwise have been pushed to a later date or after hours.
There is not much difference in the function of an NP and a PA. Whether or not an APP performs procedures is a matter of their personal preference, not determined by specific profession. Their main difference is in education.
APP education
PA training
PAs must first have earned a bachelor’s degree in any academic area. Next they must attend PA school, where they are trained in the medical model—undergoing 24–27 months of both didactic and clinical training, including medical sciences, anatomy, pathophysiology and coursework in medical specialties.
Clinical training for PAs involves rotations with physicians and PA preceptors in core medical disciplines such as family medicine, emergency medicine, internal medicine, women’s health, pediatrics, surgical specialties and behavioral health. PA students see patients in collaboration with their preceptor, conduct histories and physicals, order diagnostic studies, and develop a diagnosis. Clinical training results in more than 2,000 hours of direct patient care.
At the completion of their training program, PA students are awarded their Master of Science and are eligible to take the Physician Assistant National Certifying Exam (PANCE).
NP training
An NP’s four-year undergraduate education as a registered nurse (RN) results in a Bachelor of Science degree; prerequisites include a year of anatomy and physiology as well as chemistry and biochemistry. RNs are educated using the nursing model: assessing the patient, planning the needed care, implementing that care and evaluating the results of that plan. Nursing theory centers on the patient, the environment, health and nursing (goals, roles and functions).
Approximately 500 clinical hours are required in the areas of obstetrics, adult health, pediatrics, psychiatry and community health. The graduate nurse usually works as an RN for a minimum of two years.
The RN then goes on to obtain an advanced degree to become an NP. This requires a minimum of 1,000 hours of clinical along with didactic courses. The degree earned is either a Master of Science in Nursing or a Doctorate of Nursing Practice.
Scope of practice
As already noted, there is not much difference in the function of an NP and a PA—i.e., an NP can do all the things a PA does.
PAs work with a supervising physician providing health care for patients. PAs work in all specialties of medicine, including radiology. PAs bill under their own NPI number and can see their own panel of patients. Supervisory regulations differ from state to state, however in general delegation authority is left to the decision of the individual practice. PAs have prescriptive authority in all 50 states. Procedures performed by PAs vary from practice to practice, depending on the local hospital environment. These can range from lumbar puncture to image guided biopsies to DVT thrombolysis. In addition to procedures, PAs provide consultations, round on pre and post procedure patients, and communicate with referring physicians. PA practice at the local level can evolve over time with additional training and experience of the individual PA.
Most states require the NP to be nationally certified. The advanced clinical training allows the NP to diagnose illnesses, perform physical evaluations, treat illnesses, prescribe medications and imaging, and collaborate with other health care professionals. They are required to engage in continuing education. They bill under their own NPI number.
Hiring an APP
When hiring an APP, look for compassion, experience, self-confidence, strong analytical skills, amiability, understanding of when to ask questions and the ability to remain calm under pressure.
States and facilities may establish certain limitations and regulations, such as on the use of fluoroscopy: Some states don’t allow APPs to perform fluoroscopy, though sometimes the radiology tech can perform fluoroscopy for the APP (but not always).
Another potential requirement that is regulated by states and hospitals is whether a supervising/collaborating physician is needed. That is, a hospital within a state that grants independent practice may still require the APP to have a collaborating/supervising physician. One physician is limited by the number of APPs they may supervise.
A third challenge is whether an APP is granted procedural sedation privileges. Although advanced airway management is a requirement for sedation privileges, and most APPs have advanced cardiac life support training, some facilities still do not grant sedation privileges.
Before hiring an APP, it is important to know whether your facility has policies that regulate whether an APP can perform procedures or whether new policies will need to be created. If they will, you need to determine how long will it take to have the facility approve the policies.
Contact insurance companies in advance to advise them that your group will be hiring an APP, and that they will be billing under their own NPI number. Be sure the APP will be empaneled as a provider with the insurance companies.
Conclusion
In conclusion, hiring an APP can increase the number of procedures that can be performed in a day. It can allow the diagnostic radiologist to read, rather than be interrupted for certain procedures. Rounding on a patient the day after a procedure is billable in many cases. Inpatient rounding can generate revenue as well—in some cases, $75,000 annually. View a list of cases that do not have a global period.
The revenue generated by everything the APP does, therefore, can more than offset their salary.
Bring an APP for free to SIR 2019!
If you are an MD/DO member of SIR registering for the SIR 2019 Annual Scientific Meeting, you may bring to the meeting an APP who is also and SIR member. Learn more.
My experience as an APP
In 1996, after graduating as an NP, I left oncology and joined an IR group in central New York. Although I was their first NP, their job description specified everything they wanted me to do and the hospital granted me the required privileges. In Minnesota, I did the same work—maybe even a little more; the APPs were granted a variance by the state to use fluoroscopy.
Then I moved to California, which has a far more restrictive system. The policies for NPs to perform procedures were almost nonexistent. After two and a half years, we’ve almost obtained privileges to place ports but we won’t have sedation or fluoro privileges any time in the near future.
At a different hospital, things might be different, since some privileges and restrictions are hospital dependent, not state mandated. However, despite the state’s restrictions I am making money for the group above my salary, so they see it as a worthwhile investment.
