10 Things Radiologists Need to Know About Radiology Extenders

Medicare recently relaxed its rules on the supervision that non-physician radiology providers must have by radiologists for their respective practices to get reimbursed. In the wake of the change, these “midlevel providers” are likely to grow in importance as well as in numbers. And that may be in diagnostic as well as interventional radiology. 

For one sign of how steadily nonphysician radiology providers have already grown in importance to the specialty they serve, consider the alphabet soup of acronyms used to identify them.  

“Radiology extenders”—REs, sometimes called nonphysician providers, or NPPs—are most widely known as radiology assistants (RAs). 

Some of these professionals are RRAs, the first R standing for registered, reflecting certification by the American Registry of Radiologic Technologists (ARRT).

Those certified by the Certification Board for Radiology Practitioner Assistants are RPAs, for radiology practitioner assistants.  

Still others working under the same umbrella include radiology nurse practitioners (NPs) and advanced practice providers (APPS).  

There may be still more job titles out there. In any case, what all these folks have in common is a green light to take on some of the duties and responsibilities traditionally performed only by radiologists themselves. This may include offering—usually under the supervision of a radiologist—preliminary reads of imaging exams and, in interventional settings, making clinical recommendations to referring physicians and/or patients.  

But what to call these midlevel providers is the least of what every radiologist ought to know. Consider these 10 insights among the top aspects of which all radiology stakeholders should be aware.

1. Some leading practices are building an RE workforce, and fast.

“APPs are essential to our practice and allow our radiologists the ability to apply their experience to more complex procedures,” says Sadhna Nandwana, MD, of Emory University Hospital in Atlanta. In addition, having APPs on staff “allows for greater patient throughput, decreases wait times and delays and increases continuity of care, with the APP often serving as the liaison between referring clinicians and our patients. As such, we have rapidly expanded our APP group, which participates in both procedural and non-procedural (clinical) services within our radiology department, from less than a handful in the early 2000s to a current total of 18.”

Financial considerations also figure in REs’ favor, according to Matt Hawkins, MD, also of Emory. Last fall he published a paper in RSNA’s RadioGraphics, “Rules and Regulations Relating to Roles of Nonphysician Providers in Radiology Practices,” urging the specialty’s leaders to develop a “nuanced knowledge of appropriate coding and billing for services these professionals render.” Hawkins tells RBJ that REs “can do a lot of the same tasks radiologists can do”—for example, monitoring and managing inpatients’ progress—“at a lower cost.”

2. Medicare has put the personal supervision rule for RAs to rest, upping the ante on RA value.

Late last year CMS announced in its Medicare Physician Fee Schedule Final Rule that RAs may now perform certain diagnostic exams under “direct”  supervision rather than “personal” supervision, meaning that a radiologist need not be present in the room where the exam is taking place—only in the facility where it is being conducted. During these exams, which, for example, involve the administration of certain contrast media, the radiologist also must be immediately available to assist the RA in question if assistance is required during the procedure.

The rule, which took effect on January 1, directs Medicare to reimburse radiologists for RA-performed diagnostic procedures, providing the procedures were completed at the level of supervision mandated by the state where it occurred and within scope of practice regulations specifi ed in state RA licensure laws and standards. A majority of states that license, regulate or recognize RAs require that these individuals be supervised at the direct level, not at the personal level.

“This is a positive step for the RA profession,” says Vicki Sanders, MSRS, a registered radiology assistant who is an associate professor of radiologic sciences and the clinical coordinator of the RA program at Midwestern State University in Wichita Falls, Texas. “The ability to practice with direct instead of personal supervision makes it easier for RAs to free up radiologists to focus on what they need to focus on—and to become more valuable to radiologists in the process.” 

3. MARCA rhymes with parka, and this legislation may broaden RA reimbursement.

The CMS final rule only fixed a short list of the CPT Code 70000 Series diagnostic tests that RAs perform, notes Jason Barrett, a registered radiology assistant and radiology practitioner assistant (RPA) who works in the interventional radiology and vascular department at Kalispell Regional Medical Center in Kalispell, Montana. The rule “exempts us from ‘personal’ supervision and allows us to follow state-given scope of ‘direct’ supervision,” adds Barrett, who is a past president of the Society of Radiology Physician Extenders (SRPE). “However, it doesn’t allow radiologists to bill Medicare for the procedures we perform that involve needles—for example, arthrograms and myelograms.”

The bigger boon to RAs, according to Barrett and Sanders, will be the Medicare Access to Radiology Care Act (MARCA), under which RAs would be unambiguously recognized as nonphysician providers. The bill would allow radiologists to be reimbursed by CMS for procedures performed by RAs at the level of physician supervision required by their particular state. 

“While the CMS Final Rule was a positive step forward to let radiologists use RAs as they are trained, MARCA will secure the future of RAs by recognizing them in the Social Security Act,” Sanders says. MARCA did not pass in the 115th U.S. Congress because it had yet to be moved out of Committee when the session ended on January 3, 2019. However, Senator John Boozman (R-Ariz.) and Congressmen Michael Doyle (D-Pa.) and Pete Olson (R-Texas) are expected to reintroduce the bill in the current (116th) Congress. Th e bill is said to have strong bipartisan support, as well as a thumbs-up from the ACR, the SRPE, the American Society of Radiologic Technologists (ASRT) and others. 

4. REs can do wonders for radiologists’ workflow, potentially bolstering the bottom line.

“Radiologists gain a nice amount of time when they evaluate studies read by a radiology extender, either together with that extender or separately,” observes Arijitt Borthakur, PhD, MBA, of the University of Pennsylvania’s Perelman School of Medicine in Philadelphia. “The time gained can open doors for increased revenue.”

Borthakur and two Perelman colleagues drew the first conclusion from a study (“Improving Performance by Using a Radiology Extender,” JACR, September 2018), conducted after Penn Medicine radiologists complained repeatedly about the repetitive nature of reading plain film x-rays. 

An RE was recruited and trained to read musculoskeletal films in a similar manner to residents—i.e., using one-on-one reviews of cases read, radiologic texts and an online course. Six radiologists then read a median of 24 imaging studies under three different conditions: alone (without the RE), alongside the RE, after which they signed off on the report; and separately from the RE, with subsequent signoff. The department’s mean case flow rate (number of cases reviewed per minute) improved significantly when the RE had a hand in reviewing the studies. That rate stood at 1.33 for reviews conducted in side-by-side fashion and 1.31 for reviews conducted apart from the RE, versus 0.62 for cases reviewed without RE involvement. 

Based partially on this success, the institution now utilizes radiology extenders for ultrasound and cardiothoracic cases, as well as in the musculoskeletal section. “The workflow there is better than before,” Borthakur says.  

5. Radiology extenders can spark radiologists’ job satisfaction.

Borthakur has asked radiologists in his department to comment about the impact of RE assistance on their overall outlook. “Anecdotally, we have seen a huge improvement in radiologists’ job satisfaction—actually, their personal well-being as well as their professional well-being—when radiology extenders are involved,” he says. “They have more time to pursue interesting cases and to sit with residents to discuss these cases. We sense that residents’ engagement level, too, will increase from RE involvement.”

6. Just as patients don’t know what radiologists do, many radiologists still don’t know what RAs do.

Barrett says he has seen radiologists—especially newcomers to the specialty—who are entirely unfamiliar with the RA profession. “They are unaware that we are modality-trained by and for radiology and that we, in fact, all started out as modality-trained technologists,” he says.  

Sanders paints a similar picture. “A lot of people [within radiology] mistakenly think RAs are tech assistants, which we aren’t,” she says. “We are radiologic technologists who go through a recognized RA program with a radiologist-directed preceptorship.” Most RAs hold a minimum of a four-year college degree, she underscores, and many have advanced degrees. 

“We are certified by national certification agencies,” Sanders says. “Our background is such that we understand pathology on imaging, how to work the equipment, how to safely perform medical imaging procedures, and how to efficiently manage workflow. We can answer patients’ questions and free up radiologists to concentrate on interpreting studies. We are never a replacement for radiologists—we’re an extension of their hands.”

Findings from SRPE’s 2018 Compensation and Practice Survey also speak to the qualifications and experience that RAs bring to the table. More than one-third (38.2 percent) of respondents to the survey hold both RRA and RPA certification. An impressive 37.1 percent of respondents have been in the RA field for 11 to 15 years, and 25.1 percent have worked in some medical imaging capacity for 21 to 25 years.

7. REs are diving into the deep end of the interventional radiology pool. 

Results of the ASRT’s 2016 Wage and Salary Survey bear out the wave. Radiologic technologists surveyed were asked to name the primary discipline in which they work. Vascular interventional radiography ranked among the top six of these disciplines (3.2 percent). Rounding out the list of specialties were radiography (41.7 percent), CT (13.1 percent), mammography (11 percent), MRI (9.3 percent), and radiation therapy (8.2 percent).

“With APPs, there is less activity on the diagnostic side and more on the interventional side,” Hawkins notes, pointing to paracentesis and percutaneous biopsies as areas of common APP involvement. Tasks like evaluation and management, especially clinical follow-ups and cases for which a care plan has already been laid out, are being handled by APPs with signifi cant success, Hawkins adds.

At Emory University Hospital Midtown, radiology APPs who work on the interventional side are considered as essential to the radiology practice as those who work on the clinical side, Nandwana says.  

8. Radiology is a prime field for nonphysician providers to practice at the top of their license (or certification).  

In 2016, Nandwana led a retrospective study to evaluate and compare the procedural differences between, and diagnostic success of, biopsies performed by radiology-trained nurse practitioners and by radiologists. A total of 386 patients, all of whom had undergone a non-targeted, CT-guided renal biopsy between 2009 and 2014, were included in the study. Nandwana and colleagues concluded that radiology-trained nurse practitioners perform image-guided medical renal biopsies “in a similar fashion to radiologists” on the diagnostic success front, as well as with respect to diagnostic success, amount of tissue harvested, total radiation dose exposure, and administration of sedation.

Nandwana says the findings of the study, “Beyond Complications Comparison of Procedural Differences and Diagnostic Success Between Nurse Practitioners and Radiologists Performing Image-Guided Renal Biopsies” (Journal of the American Association of Nurse Practitioners, Oct. 2016), apply to nonphysician providers in multiple radiology sub-specialties. 

“With adequate training and supervision, nonphysician providers can be utilized to perform multiple procedures across sub-specialties and modalities,” she tells RBJ. In Emory University Hospital Midtown’s radiology department, APPs independently place drainage catheters in intra-abdominal abscesses, as well as to perform CT-guided bone marrow biopsies and ultrasound-guided fine needle aspirations of the thyroid, among myriad other procedures.

9. REs can do a lot, but they can’t do everything.

Borthakur puts complicated MRI procedures, including “anything pertaining to nuclear medicine,” in the off-limits category for REs. “The advanced medical knowledge and experience aren’t there,” he says, “and that isn’t likely to change.”  

For his part and for the same reason, Hawkins advocates keeping complex interventional procedures off radiology extenders’ plates. “I don’t foresee that changing,” he says. At the same time, he says, “I’d never say never.”

10. The RE hiring process requires doing homework and earning physician buy-in.  

So suggests James Rawson, MD, of Beth Israel Deaconess Hospital in Boston. In “Extending Radiologists and Their Groups,” a “Devilish Dilemma” column published in the January 2019 edition of JACR, Lexa and Fessell ask several radiologists how radiology groups best decide whether to implement “physician extenders.” Rawson recommends establishing clear and measurable objectives in adding physician extenders to the fold—for example, to improve patient outcomes or decrease radiologist workload. To ignore this step, he implies, is to invite trouble.  

Rawson also advocates trying to understand the mindset of each radiologist in the group. Some, he explains, will have previously worked with radiology extenders, potentially under a different set of rules, while others may have had no prior exposure to these nonphysician professionals. The likely end result: different levels of knowledge and biases to address.

“Depending on the objectives and the group’s new understanding,” he concludes, “advanced practitioners may or may not be the best solution.”