Urology Practice Management - August 2014, Vol 3, No 4 - AUA Practice Management Conference Highlights
Rosemary Frei, MSc

Urology practices in hospital and community settings can increase patient volume and revenue with the efficient use of nurse practitioners (NPs) and physician assistants (PAs), according to a presentation at the 2014 American Urological Association Practice Management Conference.

Courtney Anderson, MPA, PA-C, Clinical Coordinator and Assistant Professor, Eastern Virginia Medical School, Norfolk, VA, stated that the optimal use of these advanced practice clinicians (APCs) hinges on allowing them to use the full scope of their training and ability. Citing data from a 2013 issue of Urology Times, Ms Anderson noted that there are approximately 3000 urology APCs in the United States and growing.1

“Most practices tend to underutilize physician assistants and nurse practitioners,” said Ms Anderson. “They put them in where they are just gathering the [patient] history and not allowing them to provide diagnosis and management. They are putting them in the office and having them sit on the phone with pharmacies or insurance companies trying to deal with those administrative tasks.… If it is more the administrative aspect that your practices need, hire someone less expensive who can sit on the phone and do that.”

When considering whether to hire an APC, it is important to perform a gap analysis or a needs assessment, determine whether the physicians are willing to use APCs, and then, if so, determine which services they will delegate to the APCs. Instead of plucking from the relatively small pool of current urology APCs, she said, practices can hire NPs or PAs who have been in similar specialties and are proficient in performing procedures that are similar to urology procedures, or hire newly graduated APCs who they can train gradually under close supervision. One of the most common ways to deploy APCs is patient history-taking, physical examination, initial diagnosis, and new and returning patient management. This frees physicians to focus on complex procedures, finalize discussions regarding surgery, and manage treatment of patients with complicated conditions, explained Ms Anderson.

In a team model, APCs can work with different supervising physicians on different days, work with physicians off the same schedule, or, if they have more experience, they can run their own clinics on days when the physician is in the operating room. Care by APCs can be billed under their own provider numbers, with the reimbursement rate for Medicare patients being 85% of the physician’s Medicare fee schedule. When appropriate, their services can be billed at 100% of the physician’s rate under Medicare’s “incident to” category, if certain criteria are met.

“As long as the physician goes in and sees those patients and has some input, all are considered 100% physician care in the schedule, because [it’s “incident to” care, and] you’re going to put it under the physician’s provider identification number.”

Another approach to using APCs is the access to care or gatekeeper model, in which the APCs have a narrower scope of practice: initiating workups on new patients, screening for surgical conditions, transferring care of surgery candidates to the most appropriate urologists, and providing emergency department follow-ups.

A third model is the specialist model, which is used by several large academic genitourinary practices, and which also focuses on APC provision of nonsurgical care. APCs would see patients independently and, therefore, use their own provider numbers for billing. The length of patient visits with fully trained APCs is approximately equal to the length of patient visits with physicians, except for the more subspecialized patients, Ms Anderson said.

Billing for hospital-employed APCs’ services is somewhat similar, except that there is no “incident to” category. Instead, billing under a physician’s provider number is done under shared visit criteria, which follow the “3-sames and a some” rule, explained Ms Anderson. This means the APC and the physician have to have the same employer, have to see the same patient on the same day, and there has to be some face-to-face time between the patient and the physician. Shared visit billing pertains only to evaluation and management and cannot be done for an initial consult or procedures.

A relatively new phenomenon involves APCs performing ultrasound-guided prostate biopsies and flexible cystoscopy, noted Ms Anderson. She cited that at Emory University, hundreds of prostate bi­­opsies are conducted annually, and the university’s 4 PAs perform about 70% to 80% of them. The PAs’ reimbursement rate is about 90% of the urologists’ rate, and they are paid about a third of what the physician would be paid. The same may occur with cystoscopies, with more APCs perhaps doing these for difficult catheter placement, said Ms Anderson.

She also described 4 factors that are necessary for the successful integration of APCs, particularly in hospital-based practices but also in freestanding clinics2: (1) whether the group’s physicians buy into the APC paradigm, including agreeing to provide the necessary training on an ongoing basis; (2) whether the group is stable enough to support the incorporation of APCs; (3) whether there is an accurate understanding of how to bill for APC services; and (4) whether qualified APC candidates are available.

“If you don’t have the infrastructure in place to deal with multiple different providers, people in different settings at the same time, if you don’t have enough nursing staff or medical assistants, enough people with knowledge of proper scheduling…it won’t fly. Make sure your group is stable, then know how to bill for it. It is so important.”

Hospital-based APCs can perform patient rounds, consults/histories, physicals, admissions, and discharges; act as initial responders; perform appropriate diagnostic and therapeutic procedures; be the genitourinary representatives in multidisciplinary care teams; and be surgical first assistants.2 It is best for APCs to perform these activities alongside 1 or 2 physicians, said Ms Anderson.

“On any individual day, don’t have 4 physicians expecting to be able to utilize that nurse practitioner or PA at their whim…,” Ms Anderson said. It also may be optimal to have APCs perform activities such as surgical assisting and patient rounds on days separate from clinic-based activities to avoid shifting patients between clinicians if responsibilities at the hospital take longer than expected. Ms Anderson explained that although scheduling could be challenging at first, particularly in some of the larger hospitals where it is uncertain at any one time how many consults or patients you’re going to have, it will become easier with practice.

It can take effort to determine what roles APCs can play in each urology practice, and to find the right people to fill those roles, but it can be well worth it, Ms Anderson concluded.


  1. Hilton L. Non-physician providers: allied or disparate? Urology Times. July 30, 2013. http://urol Accessed July 9, 2014.
  2. Use of Non-physician Clinical Staff in Hospitalist Programs – Chapter 8. Society of Hospital Medicine. source=web&cd=1&cad=rja&uact=8&ved=0C CkQFjAA& Key%3Ded0642ef-e72e-428e-bb5b-5bec8dee83d0%26ContentItemKey%3D85c8f112-e195-4e8b-b0c0-f8 9f2705edf1&ei=co3GU6PbLY3gsATx94CwAQ&us g=AFQjCNFdaTJf_lZgPcXvFIUaA90Kimt6k g&sig2=uQU2NGcVvQM_aI8uAMCxow. Accessed July 16, 2014.
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Last modified: August 5, 2014
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