The Reading Room

Member Question: Physician Assistant Supervision of Interventional Procedures

The partnership recently received an interesting question from a member and I thought I would share our answer. The member asked:

"Can a physician assistant perform interventional procedures such as fluoro-guided lumbar puncture, CT guided biopsy and drainage, paracentesis, thoracentesis, PICC placement, etc, without physician supervision, so long as they have a radiologic technologist on hand to "step on the pedal" for the X-Ray or CT scan?"

This is a complicated question that tends to cause a lot of confusion. It also entirely depends on both the type of procedure performed and the regulations of the state it is being performed in. 

Here are the salient facts from CMS:

  • For the most part, interventional procedures, such as those described above, that employ fluoroscopy or that are CT guided require "personal" physician supervision, which means a licensed physician must be present in the procedure suite throughout the procedure. This applies, for the most part, to all outpatient settings, including hospital outpatient settings. (Critical Access Hospitals have slightly different arrangements)
  • Nurse practitioners and physician assistants are not considered physicians; therefore they are not permitted to function as supervising physician in this case. 
  • However, according to CMS, NPs and PAs are exempt from the above physician supervision requirements when performing diagnostic tests. They may perform these procedures without "personal" physician supervision as long as they abide by their state's PA/NP scope of practice laws.

So according to federal regulations, the PA in question could perform the exams on his own, even without the RT in the room. However, on a state level, things get more problematic. Specifically, many states prohibit PAs from performing medical services that involve the provision of ionizing radiation:

  • As of 2010, all but six states and the District of Columbia have enacted provisions to require that those who use ionizing radiation on human beings are properly certified.
  • Eight states currently exempt PAs from requiring an RT license to use ionizing radiation
  • Twelve additional states and the District of Columbia do not currently regulate RTs, so PAs are not prohibited by law from using ionizing radiation if delegated to do so by a supervising physician. 
  • In ten states PAs who have had additional training may take x-rays or use fluoroscopy in specified circumstances. 
  • PAs in the remaining 20 states must possess some sort of radiographer license in order to utilize ionizing radiation.     

So, provided that your PA is in a state that doesn't regulate the provision of ionizing radiation, or one that exempts PAs from these regulations, your PA would be able to perform these procedures on their own.

But, if you are in a state that does not permit PAs to utilize ionizing radiation without RT certification, does having an RT "step on the pedal" help? The answer is no. The RT would still require, as mentioned above, "personal" physician supervision to perform the above exams, and the PA would still be prohibited from functioning as a supervising physician. Therefore having the RT "step on the pedal" for the PA without a physician in the room would still be prohibited. Note that this only applies to exams that require "personal" physician supervision. If the exam only required general or direct physician supervision, then the RT might be able to perform the exam with or without the PA in the room.