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Current State of Advanced Practice Providers in Urologic Practice

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Introduction and Purpose

The purpose of this document is to provide guidance for urologists on the integration of advanced practice providers (APP) into the urological care setting with a focus on the current state and federal regulatory environment, reimbursement considerations, core competency benchmarks for APPs, patient satisfaction with the APP-physician team approach, and proposed models of team-based integrative care.

A workforce shortage of 65,000 physicians is projected for both primary care and specialty medicine by the year 2025.¹ Similarly, the supply of urologists per capita in the United States continues to decrease, a trend that started in 1991 and continues to accelerate. In 2018, there were 3.89 urologists per captia, which is only a modest improvement from 2009, where there were only 3.18 urologists per 100,000 in the population, which was a 30-year low and amongst the most severe specialty medicine shortages. This is compounded by the fact that urology has the second oldest surgical subspecialty workforce with an average age of 52.5 years and of whom greater than 18% are age 65 years or older.²

According to a 2019 study from the Association of American Medical Colleges (AAMC), the projected physician shortage is between 46,900 and 121,900 physicians by 2032, including both primary care (between 21,100 and 55,200) and specialty care (between 24,800 and 65,800).

However, the supply of physician assistants (PAs) and advanced practice registered nurses (APRNs) is projected to continue to increase. The AAMC report models their role in providing health care, but further research is required on the types of services these professionals are providing, and if, or at what point, the supply of PAs and APRNs will become saturated.

Emerging health care delivery trends designed to improve overall population health do not have a significant effect on physician shortage projections. The report’s first-time analysis showed that emerging health care delivery trends, including providing better care coordination across settings, reducing unnecessary hospitalizations and emergency visits, increasing use of advanced practice providers (APPs), reducing obesity and tobacco use, and applying managed care models and risk sharing agreements such as Accountable Care Organizations, will only reduce demand for physicians by 1% by 2032. However, this analysis is presented as new work and will be refined further before being included in future overall shortage estimates.

In 2010, the Institute of Medicine (IOM) addressed the role of APPs and the impending physician workforce deficits within the document “The Future of Nursing: Leading Change, Advancing Health.” The committee concluded in their report to Congress that the increase in primary care reimbursement in the Medicaid program should be extended for the services of APPs; that the Medicare program should be expanded, with encouragement to private insurance to reimburse the services of APPs within the applicable state scope of practice legislation; and that Congress should consider limiting federal funding for nursing education to only those states that have adopted National Council of State Boards of Nursing APRN model rules and regulations.³ In response to this IOM report, the American Medical Association (AMA) acknowledged the workforce shortage of both nurses and physicians and endorsed a physician-led team approach to the provision of high-quality, value-based health care through “each team member playing the role they are trained and educated to play.”⁴ However, recent data indicate that states with the least restrictive scope of practice laws have experienced the largest increase in the number of APPs that independently provide primary care and medication prescribing services for Medicare patients without physician supervision.⁵

The American Urological Association (AUA) endorses the use of APPs in the care of patients with genitourinary disease through a formally defined, supervised role with a board-certified urologist under the auspices of applicable state law.⁶ Based on an AUA Office of Education needs assessment survey from October to November 2012, nearly 8,000 APPs were working in urology practices/institutions in the United States, including 3,338 nurse practitioners (NPs), 4,002 PAs, and 411 clinical nurse specialists (CNSs). The survey results showed that 65% of urologists were interested in the integration and utilization of APPs in their practice.⁷ According to the 2018 census, 72.5% of urologists used an APP in their practice, and APPs accounted for 41% of an MD/DO full-time equivalent, of which 75% were ambulatory clinic-related, 14% inpatient-related, and 9% procedural-related . The utilization of APPs was lowest in the youngest and oldest subgroups of urologists (29% 25-45 years; 52% 46-55 years; 19% >55 years)⁸, and APP utilization was highest in urban urologists (68% urban, 58% suburban, and 51% rural) and in larger group sizes. Approximately 90% of urology APPs work in metropolitan areas.⁹ Utilization also appears to be greater amongst academic and employed urologists in the middle years of their career. NPs are more likely than PAs to work in institutional practices (59%), like academic medical centers, medical schools, and hospitals (42%).⁹

Most APPs primarily work in general urology while NPs are more likely than PAs to work in urology specialty areas such as oncology and pediatrics. Specialty areas in which APPs are more likely to work are erectile dysfunction (61.4% of PAs and 53.4% of NPs), oncology (52.3% of PAs and 37.8% of NPs) and endourology/stone disease (47.2% of PAs and 34.3% of NPs).⁹

Definitions

As of February 2014, the AUA recognizes APRNs and PAs as Advanced Practice Providers (“APPs”). The term “allied health professional” applies to nurses (registered nurses [RNs], licensed practical nurses [LPNs], and licensed vocational nurses [LVNs]), technicians, and medical assistants.

Defining the NP role

“APRN” is a term that covers four distinct areas of certification: certified NP, certified nurse midwife (CNM), Clinical Nurse Specialist (CNS), and certified registered nurse anesthetist (CRNA). The 2008 APRN regulatory model established these four categories and denoted advanced graduate nursing preparation specific to each of these areas of certification.

Each APRN obtains a Bachelor’s of Science in Nursing (BSN) prior to admission to a graduate program, though some students may have additional undergraduate and graduate degrees. The student APRN then undergoes a population-focused but broad-based education at the graduate level and sits for a national certification examination to assess competencies of their specific core and at least one population focus area (such as adult-geriatrics or pediatrics). After passing the certification examination, individuals are licensed as independent practitioners subject to the specific regulation of a state board of nursing. Licensing implies congruence between certification, licensure, and population focus. An APRN cannot be licensed only in a specialty area, such as urology, but must first be certified in one of the four generalist APRN categories. The academic degree granted is either a Master of Science in Nursing (MSN), a Master of Science (MS), or a Doctorate of Nursing Practice (DNP), depending on the individual program. Initial certification requires evidence of degree status and at least 500 hours of clinical practice, although these requirements vary depending on the specific certifying body.

Recertification is required every five years with varying numbers of continuing education units (CEUs) and proof of ongoing clinical experience. However, the initial certification examination does not have to be retaken unless the certification expires. For the purposes of this consensus statement, the discussion will focus only on the NP role because Quallich and colleagues established that among these four generalist categories, it is only NPs who are sustaining a specialty practice in urology.¹⁰ Descriptions of the other three roles can be found in Table 1.

NP education includes a graduate degree or postgraduate certificate that is awarded by an accredited academic institution (university or college), of which there are approximately 400 with NP programs in the United States. NP training provides theoretical and evidence-based clinical knowledge and includes didactic classroom training followed by clinical rotations. The training is based in primary care, with additional education if they intend to become a CNM, CNS or CRNA. Specific classes within the NP curriculum include advanced pathophysiology, advanced pharmacology, advanced health assessment, population-specific content, health promotion strategies, and basic research and statistics courses. In clinical practice, this represents a process for care that includes assessing health status, formulating a diagnosis, developing and implementing a treatment plan, and continuing follow-up and evaluation of the patient.

Table 1. Descriptions of non-NP/APRN roles
Certified Registered Nurse Anesthetist (CRNA): An APRN who provides the full spectrum of anesthesia and anesthesia-related care for individuals across the lifespan and through all levels of acuity. This care can be administered in diverse settings, including hospital operating rooms and pain management services. Some CRNAs specialize in particular settings or populations, such as pediatrics.
Certified Nurse Midwife (CNM): An APRN who provides the full range of women's primary reproductive health services focusing on gynecologic care, family planning services, childbirth, and newborn care. This role can include treating male partners for sexually transmitted infections. Their practice settings can be diverse and include homes, birthing centers, and hospitals.
Clinical nurse specialist (CNS): An APRN who integrates care, focusing on the interactions of patients, nurses, and systems. A continuous focus of this role is improvement of patient outcomes and nursing care with the goal of developing evidence-based practice to improve overall patient care within a system. Specific roles can include diagnosis and treatment of health and illness, health promotion, and risk factor prevention among families, groups, or communities.

NPs are often members of a larger team that provides comprehensive health and medical care to specific populations or in specific care environments. This model emphasizes health education, promotion of optimal health, and the facilitation of patient participation in self-care. The NP provides care for patients across the health continuum and functions in diverse settings, such as geriatrics, women's health, pediatrics, and specialty practices. The role of the NP includes diagnosis and treatment of both acute and chronic conditions. This extends to comprehensive history and physical examination; preventative screening and health assessment; ordering and interpreting laboratory and imaging studies; and prescribing medication, physical and occupational therapy, and durable medical equipment. This role often includes health education and teaching individuals, families, groups, and other members of health care team. Many NPs practice in primary care settings, but others have roles within specialty and subspecialty practices.

Defining the PA role

Prior to admission to a PA program, students must at minimum complete an undergraduate degree, with a minimum of two years of college courses in basic or behavioral sciences. PAs re medical professionals who have graduated from a PA program accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)¹¹, of which there are approximately 235 in the United States, and who are also nationally certified and state licensed to work with the supervision of a physician. PAs undergo training based on the medical model with a focus on primary care programs typically extend over about 27 continuous months or three academic years, compared to about 38 months for medical school. The first phase of PA school (the didactic or classroom phase) covers basic medical sciences, including anatomy, physiology, pharmacology, physical diagnosis, behavioral sciences, and medical ethics. In total, PA students complete more than 75 hours in pharmacology, 175 hours in behavioral sciences, more than 400 hours in basic sciences, and nearly 580 hours of clinical medicine.¹¹

The didactic training is followed by a clinical year consisting of required core rotations in family medicine, internal medicine, pediatrics, general surgery, obstetrics/gynecology, emergency medicine, behavioral health, and geriatrics as well as elective specialty rotations including where available in urology. The clinical rotations for PAs emphasize primary care and prevention in both inpatient and outpatient settings.

Beginning in 2020, all PA programs must confer a master’s degree in order to maintain accreditation. Graduates of an accredited PA program are eligible to take the Physician Assistant National Certification Examination (PANCE) for certification and licensure. Eligibility for certification involves evidence of degree status and at least 2,000 hours of supervised clinical practice in various settings. Recertification occurs every 10 years with yearly continuing medical education (CME) requirements. PAs are licensed by the state board of health and are under the same jurisdiction as physicians. Although not required, certified PAs can also earn Certificates of Added Qualification (CAQ) in seven specialties: cardiovascular and thoracic surgery, emergency medicine, hospital medicine, nephrology, orthopedic surgery, pediatrics, and psychiatry.

In clinical practice, the role of a PA is as part of a team practicing medicine with physician supervision and is frequently described as delegated autonomy. The PA model of education emphasizes disease prevention, elimination of health disparities, and promotion of health and healthy behaviors. PAs provide care for patients across the health continuum and function in diverse settings that can include internal medicine subspecialties, acute care environments, general surgery, and surgical subspecialties. This extends to comprehensive history and physical examination skills; preventative screening and health assessment; ordering and interpreting laboratory and imaging studies; prescribing medications; and assisting in surgery. Although PAs do not specifically specialize with a population focus within their training program, PAs can obtain additional post-graduate fellowships in urology, general surgery, emergency medicine, or orthopedics.¹² For additional information visit the Association of Postgraduate PA Programs

NP and PA training

It is clear from the descriptions of the NP and PA roles that while their training may be different, their roles after certification can be quite similar. Regarding training, NPs rarely undergo clinical rotations where they might have the opportunity to assist in surgery, but this is required in all PA programs. Another primary difference is that NPs specialize with a particular population focus prior to achieving their graduate degree, while PAs may move to specialize with a particular population after graduation. Another difference between NPs and PAs is the number of clinical practice hours required for certification (500 hours for NPs and 2000 for PAs). However, it is important to note that all advanced practice nurses have prior experience working as registered nurses, which accounts for the reduction in clinical practice hours required for certification.

Supervisory/collaborative model

Supervision/collaboration is a process in which an APP works with one or more physicians to deliver health care services within the scope of the practitioner’s expertise with medical direction and appropriate supervision as supported by jointly developed guidelines or other mechanisms as indicated by the law of the state in which the services are performed. This requires that each party share responsibility for care. Supervision/collaboration is an interactive process involving trust, excellent communication, mutual goals, and common direction in practice as well as a dynamic process dependent upon the skills and competencies of both the APP and physician. An important component of collaboration requires professional relations that foster the best patient outcomes and the optimal use of individual skills. This team model is an efficient way to provide high-quality medical care.

The official position of the AUA is that APPs work in a closely and formally defined alliance with a urologist who serves in a supervisory role. This physician-led, team-based approach provides the highest quality urologic care.¹³ As the physician-led, team-based approach evolves, so do the definitions of supervisory and collaborative models of care between physicians and APPs.

The role of APPs in a urology practice is dependent upon many factors, including academic vs. private practice, large vs. small group, APP experience, facility and practice needs, physician comfort level, and state laws. The supervisory/collaborative model may be described as delegated autonomy. This model fosters an appropriate growth in autonomy time as the physician and the APP become accustomed to working together.

In 1995, the AMA acknowledged the importance of requiring supervision while allowing physician flexibility in practice management. The AMA House of Delegates adopted the Guidelines for Physician/Physician Assistant Practice, which posits:

The role of the PA in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the PA and based on the physician’s style of delegating.
The physician must be available for consultation with the PA at all times either in person or though telecommunication systems or other means.
The physician is responsible for clarifying and familiarizing the PA with his or her supervising methods and style of delegating patient care.

Although the physician is responsible for the overall care of the patient, the concepts of supervision and collaboration do not require that the supervising physician (SP) be present with the APP during APP-provided care. As the physician-APP relationship grows and evolves, the duties delegated to the APP are designed to deliver quality health care while freeing time for the physician to attend to more complex patient care suited to his or her level of expertise. Highly skilled APPs are eligible for this indirect supervision.

Given the specialty nature of urology and the lack of intensive curricula in NP or PA programs, the supervision/collaboration model likely promotes the best patient care outcomes in urology. In most instances, prior urology experience is limited, and for that reason, sound problem solving and decision-making skills will mature with time. Delegated tasks must be mutually understood and agreed upon. As such, it is important that team members realize their potential for efficiency and high-quality care requires appropriate support, encouragement, and training tailored to the experience level of the APP. Newly graduating APPs and APPs new to urology will require frequent physician-APP communication and a period of direct supervision and orientation.

Models of team-based integrative care should be based on the needs of the particular practice. Examples can include assisting in surgery, seeing postoperative patients, hospital consults, emergency room consults, and overflow office patients. Outreach clinics can also be staffed by experienced APPs, and preoperative and postoperative educational classes conducted by APPs can increase patient satisfaction and patient retention. In the hospital setting, consultations, history and physical examinations, and difficult bladder catheterizations can be performed by APPs. Allowing APPs to perform these types of tasks enables the physician to dedicate more time to more complex urologic patients within the practice.

In the clinic setting, some procedures, such as prostate ultrasound, urodynamics, cystoscopy, vasectomy, and stent removal, have been performed by APPs; however, this is an area of controversy requiring further study. Factors such as APP education level, APP proficiency with procedures, state scope of practice laws, and the level of comfort for the supervisory/collaborative physician must be considered in order to maintain the highest quality urologic care and patient safety.

State laws governing APP supervision can have subtle differences between states. States that have restrictive language regarding the physician’s delegating authority are challenged and modified regularly. The purpose of these challenges is to improve the physician’s ability to extend access to care through physician-APP teams. An increasing number of states now use language that defines supervision more broadly and are repealing laws that require physicians to be present at their practices for a set number of hours. Currently, 22 states, the District of Columbia, and Guam grant NPs the right to have their own completely independent practice.

The most effective physician-APP team practices provide optimum patient care by designing a practice model in which the skills and abilities of each team member are used most efficiently. Ideally, physicians are not involved in care best provided by APPs and similarly, APPs do not undertake tasks best provided by physicians. Studies consistently find enhanced quality of care in settings that fully integrate physician-APP practice.

Core competencies

It is a goal of the AUA and of practicing urologists to develop a process in which newly graduated APPs undergo a period of mentorship and training to cultivate practitioners who are capable and willing to independently manage a wide variety of urologic conditions. This is not dissimilar to the training and mentorship that goes into training junior urology residents, who are groomed to be capable of indirect supervision for most encounters in the area of urologic health.

The Urology Milestone Project describes several core competencies as well as progression in skills, independence, and capability that a developing resident must achieve to increase their level of training. As outlined in Table 2, the core competencies of certified and licensed APPs are not dissimilar to what is expected of urology residents throughout their training.¹⁴ As APPs increase their skills (Table 2), decreasing levels of direct supervision are necessary commiserate to the individual’s demonstrated level of aptitude. This will obviously occur at different rates based on the complexity of the diagnosis that is being managed and the specific clinical environment, as well as the number of encounters and acuity of the patients who are seen. Ultimately, the goal is that the APP will be fully capable of remote supervision for most complex diagnoses and management plans after an appropriate period of mentorship and experience.

Table 2. Comparison of core competencies guiding NP and PA education programs and Accreditation Council for Graduate Medical Education (ACGME)/American Board of Urology (ABU) competencies
Milestone Concepts	Resident Competency Adpated from "urology Milestone Project" Document	Nurse Practitioner Competency Adpated from National Organization of Nurse Practitioner Faculties (NONPF) core competencies, 2011 (updated in 2012) 9 categories of compitencies	Physician Assistant Competency: Adapted from American Academy of Physician Assistants (AAPA)/Physician Assistant Education Association (PAEA) core competencies (revised in 2012) 6 categories of competencies
Foundation in urologic/medical and scientific knowledge	Patient care, practice-based learning and improvement, medical knowledge	Scientific foundation	Medical knowledge, patient care
Leadership	Practice-based learning and improvement, interpersonal and communication skills, professionalism	Leadership	Professionalism, interpersonal and communication skills
Evidence-based practice	Practice-based learning and improvement	Quality, scientific foundation	Patient care, practice-based learning
Quality improvement and research	Practice-based learning and improvement	Practice inquiry	Systems-based practice, practice-based learning
Use of technology in patient care	Systems-based practice	Technology and information literacy	Systems-based practice
Health care policy, regulation	Systems-based practice	Policy	Professionalism, systems-based practice
Organizational practice/resource allocation	Systems-based practice, professionalism, interpersonal and communication skills	Health delivery system, quality, ethics, health delivery system	Interpersonal and communication skills, systems-based practice, professionalism
Role as part of health care delivery team	Systems-based practice, practice-based learning and improvement, professionalism, interpersonal and communication skills	Independent practice, health care delivery system	Systems-based practice, professionalism
Patient care/professional ethics	Professionalism, interpersonal and communication skills	Ethics, quality	Professionalism, patient care
Scope of practice	Professionalism	Independent practice	Medical knowledge, professionalism
Procedural competencies	Patient care	Independent practice, scientific foundation	Professionalism, medical knowledge, practice-based learning
Note: Competencies not incorporated in this chart are related to resident surgical skills/training.

NP-specific competencies were created by Quallich, Bumpus and Lajiness15 and can be used as a metric to guide training and evaluation of new APPs. Although the training and clinical experience of new APPs cannot be directly lateralized into an easily transferrable assessment of level of urologic expertise, a baseline assessment of clinical skill and knowledge in general urology or a specific dimension within an area of urology (e.g., sexual dysfunction or incontinence) may be ascertained over time with close mentorship. This would allow for additional education, both didactic and clinic-based, to meet the needs of a particular practice environment. An APP who moves into urology with previous experience independently managing patients would enter this process at a much different point and may require more urology-specific knowledge and less clinical management training.

This can progress to a point at which the APP is sufficiently “expert” and may potentially offer a subspecialty service, with supervision, to meet the needs of urologic patients and fulfill a practice gap that is expanding in subspecialty urologic care. As APPs are trained to function at high levels within urology or a urologic subspecialty, resources may be redirected to the mentorship of more junior APPs to continue building a quality service in our specialty of urology. This may prevent the movement of patients to other specialty fields that are not as well equipped to manage the urologic problems or the acuity of problems that urologists or a team of urologic providers are prepared to treat.

The skill levels of care, derived from the core competencies outlined in Table 2, are built on the basic knowledge of APPs and demonstrate the similarities that form the groundwork of the education and additional training for residents and APPs. Implementation of these levels of supervision and expectations regarding quality of care are subject to the expectations and experiences of the individuals involved as guided by specific state and facility guidelines. These levels of supervision have been defined by applying the outline of the competencies that are recognized as vital for residents to the role of APPs in urology. This reflects a process for how APPs may progress through increasing levels of expertise, which in turn indicates their ability to independently care for higher acuity and more complex patients with decreasing levels of supervision.

The following skills have been adapted from the review by Crecelius and colleagues.¹⁶

Level 1 skills

This level describes a highly skilled, expert clinician. The physician and APP will likely communicate routinely via distance communication such as email progress notes or telecommunication. Notification of changes to treatment plans or a new significant diagnosis usually occurs promptly by HIPAA-compliant methods. Given the competent skill set, this APP-physician team can focus on care collaboration. As highly skilled members of the care team, the APP is often responsible for quality improvement initiatives. Families, patients, and staff will probably trust the APP and physician equally. This team is ready to conduct educational sessions pertinent to urologic health. APPs with Level I skills may staff specialty (e.g., sexual function, men’s health, or pelvic pain) clinics within urology. This APP is likely to be involved in research and publication and may present at local and national conferences.

Level 2 skills

This skill set may describe an experienced APP who is new to urology. The APP possesses basic knowledge and is expected to mature to Level 1 skills over time under the mentorship of a urologist. The role of the physician is to verify, validate, and provide constructive feedback. This can be done via telephone for most circumstances, but ideally some time should be spent face-to-face. The APP will benefit from opportunities to enhance diagnostic and therapeutic skills in caring for complex patients with multiple or complex urologic conditions and those with multiple medical comorbidities. Before talking with families and patients about more complicated interventions or weighing options, the APP may want to discuss and coordinate with the physician and plan the ideal approach for this communication with the patient or family. The physician will want to be clear on what to delegate to the APP and make sure that the APP is comfortable with this level of intervention. Trust between the APP and the patient, family, and staff should grow as skills develop. Continuing education workshops in which the APP learns from other skilled practitioners will be helpful (e.g., APP sessions at AUA national meetings).

Level 3 skills

This level may describe a newly graduated APP who is also new to urology. Level 3 refers to an APP whose skill set in managing urologic conditions is immature. Supervising this APP is essential to ensure safe care. This APP may have difficulty triaging multiple complaints and determining which clinical course is best. The physician will initially want to personally examine or at least make face-to-face contact with each patient seen by the APP. The physician and the APP may want to consider a urology training curriculum, such as the AUA APP modules. Orientation to the urology APP role may focus on routine follow-up of stable patients or shadowing the physician for higher acuity or complex patients. It may be that the APP is not ready to prescribe urology-specific medications until discussion with the physician. The APP should move toward Level 2 in a matter of weeks to months. If this is not the case, the APP should consider another environment where closer supervision is available or determine whether urology is best suited for him or her.

The AUA has recognized the need for additional educational opportunities regarding the best practices in implementing urologic team-based care. The 2017 AUA Educational Needs Assessment conducted by the Office of Education indicated that 79% of respondents who use APPs find they improve practice efficiency, and 49% find APPs extremely valuable to practice and patients.¹⁷ The AUA Education Council and APN/PA Education Committee has identified six topic areas in which training modules will be developed to assist in APP training and integration. These topic areas are:

Overactive bladder/non-surgical
Urologic oncology
Male sexual dysfunction
Surgical assistance
Stone management
Female sexual dysfunction

These modules will be available on the “Education for APN/PA/Allied Health” portion of AUAnet.org.

Federal regulations

The Social Security Act, Medicare regulations, national medical and nursing associations, federal agencies, and state guidelines provide recommendations and define the supervisory role of physicians and how physicians and advanced care providers collaborate.

Statutory requirements

Supervision regulations at 42 CFR 483.40 (a)(1) state, “The medical care of each resident [patient] is supervised by a physician.” The regulatory definition of “collaboration” is defined at 42 CFR 410.75 (c) as:

“(i) Collaboration is a process in which a nurse practitioner works with one or more physicians to deliver health care services within the scope of the practitioner’s expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as provided by the law of the State in which the services are performed.

(ii) In the absence of State law governing collaboration, collaboration is a process in which a nurse practitioner has a relationship with one or more physicians to deliver health care services. Such collaboration is to be evidenced by nurse practitioners documenting the nurse practitioners’ scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. Nurse practitioners must document this collaborative process with physicians.

(iii) The collaborating physician does not need to be present with the nurse practitioner when the services are furnished or to make an independent evaluation of each patient who is seen by the nurse practitioner.”

Mediare (billing) regulations

In the Medicare Benefit Policy Manual and Medicare Claims Processing Manual, “incident to” services are noted as integral yet incidental to the professional and personal services of a physician in diagnosing and treating illness. Thus, they may be performed by nonphysician personnel and still be billed as if the physician personally performed them. However, essential rules must be followed to correctly bill such cases to Medicare.^{18, 19}

They must be performed in the physician’s office. Hospital inpatient services do not qualify.
Those performing the services must be employed by the billing practice.
The physician must have personally performed the initial service for a new patient to the practice, have established a plan of care, and remain actively involved in the course of treatment. The same is true for any established patient with a new medical condition. Other practice employees may implement incidental steps in the established plan of care within the scope of practice limits in their state.
While “incident to” services are taking place, a physician must be physically present in the same office suite and be immediately available to render assistance if necessary. This is described by Medicare as “direct supervision.” It need not be the physician who performed the initial service, but it must be a physician-member of the group.
Medicare reimbursement is based on 100% of the physician fee schedule amount. Unless these rules are followed, such delegated services by an APP are only paid at 85% of the physician fee schedule, and those delegated to other practice employees are not reimbursed at all.
It is important to review the contracts for other third-party payors that cover your patients as well as your state’s laws to determine to what extent you can delegate services for non-Medicare patients and how much you can be reimbursed. This will help your practice make wise decisions about how and when to delegate services.

Federal legislation

In the 115^th and 116^th Congresses, federal bills were proposed concerning a range of health care-related issues. Bills and initiatives specific to NPs include expanding authority to conduct assessment for patient admission to skilled nursing facilities, expanding Medicare reimbursement rates for non-physician providers to be similar to those of physicians, and expanding prescribing privileges.

Federal legislation has been proposed that would impact PAs in similar ways, namely expanding their scope of practice, including legislation to allow PAs to order home health services for Medicare patients and authorizing PAs to receive direct payment under Medicare. In addition, PAs have asked Congress to make permanent the authorization for NPs and PAs to provide lifesaving, medication-assisted treatments to patients battling opioid use disorder.

National medical organizations on APP supervision

AUA

The AUA’s most recent policy position on APPs in urologic practice states:

Role of Advanced Practice Providers and Other Allied Health Professionals

The AUA endorses the participation of advanced practice providers and allied health professionals in the care of genitourinary disease through a formally defined, supervisory role with a urologist certified by the ABU, AOBS or other certifying board for urology, under the auspices of applicable state or national law.

The American Urological Association (AUA) and the Urology Care Foundation recognize that in some areas, allied health personnel contribute to the care of the patient with genitourinary disease and, therefore, encourages the proper utilization of APPs.

Allied health personnel should be considered as para-professionals and should work in a closely and formally defined alliance with a physician.

Where the major duties of allied health personnel (i.e., NP and PA) are those of diagnosis, treatment, or management of [patients with] urological disease or problems, the designated supervising physician should be a urologist certified by the American Board of Urology (ABU).

The AUA recognizes that the role and privileges of allied health personnel vary according to individual state regulations and that the restrictions and/or controls established in any state should be honored.”

AMA

The AMA’s position is founded on a physician-led team approach to care with each member of the team playing the role they are educated and trained to play.²¹ The AMA’s House of Delegates also passed a policy statement titled Support for Physician Led, Team Based Care²¹ that requires the AMA to advocate to policymakers, insurers, and other groups, as appropriate, that they should consider the available data to best determine how nonphysicians can serve as a complement to address the nation’s primary care workforce needs; to continue to recognize nonphysician providers as valuable components of the physician-led health care team; and to advocate that physicians are best qualified by their education and training to lead the health care team. A June 2017 policy titled Guidelines for Medical Health Teams details the four elements to consider when planning a physician-led, team-based approach to care according to the needs of each practice: patient-centered, teamwork, clinical roles and responsibilities, and practice management.²²

AANP

The American Association of Nurse Practitioners (AANP) seeks to remove limitations in federal laws and regulations that do not recognize the advanced education and clinical preparation of NPs that allows them to furnish the full range of services they are licensed to provide, including ordering, conducting, supervising, and interpreting diagnostic and laboratory tests and prescribing pharmacological agents and nonpharmacologic therapies.²³ In particular, the association has focused on providing coverage of NP services as physician services are covered and seeking recognition as primary care providers in all programs and settings.²⁴

The AAPA seeks to support “optimal team practice.” To do so, the AAPA says that states should: eliminate the legal requirement for a specific relationship between a PA, physician, or any other health care provider in order for a PA to practice to the full extent of their education, training, and experience; create a separate majority-PA board to regulate PAs or add PAs and physicians who work with PAs to medical or healing arts boards; and authorize PAs to be eligible for direct payment by all public and private insurers.²⁵

The policy environment and implications for the future

In the current policy environment, some suggest that states could improve access to primary care by easing the scope of practice restrictions and modifying reimbursement policies to increase the role of NPs in providing primary care;²⁶ expanding the Medicare program to include coverage of APRN services that are within the scope of practice under applicable state law just as physician services are covered;³ amending the Medicare program to authorize APRNs to perform admission assessments and certification of patients for home health care services and for admission to hospice and skilled nursing facilities;²⁶ and extending the increase in Medicaid reimbursement rates for primary care physicians included in the Patient Protection and Affordable Care Act to ARPNs.

State legislation has also been introduced that would impact PAs in similar ways, namely expanding their scope of practice. In 2019, several states passed legislation that expanded the PA scope of practice. For example, West Virginia passed SB 668, which allows PAs practicing in a hospital to submit a notification in writing to the board that the PA will work in collaboration with one or more physicians in a hospital. SB 668 was signed by Governor Jim Justice and became effective in June 2019. North Dakota passed HB 1175, which eliminated the requirement for a PA to have an agreement with a specific physician in most settings. Governor Doug Burman signed this bill into law and it became effective in August 2019. Lastly, South Carolina passed S. 132, the “PA modernization bill,” which eliminated the requirement for a PA to practice within a certain distance from their physician partners. S. 132 also allows PAs to sign specified clinical patient-related documents that their SP signs to expedite patient care. S. 132 was signed by Governor Henry McMaster and became effective in August 2019.

In 22 states and the District of Columbia, NPs are allowed to practice independently, while 12 states require NPs to be supervised (directly or indirectly) by a physician. The remaining 16 states require NPs to have a collaborative or supervisory agreement with a physician. Governmental bodies, such as the Health Services and Resources Administration’s National Advisory Council on Nurse Education and Practice, have stated that nonphysician providers might improve the shortage of primary care physicians and specialists and suggested that states allow NPs to perform at the highest level of their scope of practice. NPs also are seeking independent practice in the 16 states that do not allow it at the time of this writing. Regardless of whether a state allows independent practice, federal regulations in some settings (such as nursing facilities) take precedence over state regulations and may require that a physician supervise or coordinate patient care.

In addition to statutory and regulatory requirements, it is important to note that each employer, hospital, or payor may have unique requirements and policies surrounding the role of APPs. Payors may reimburse services and procedures performed by APPs at lower rates than those of physicians or refuse to reimburse for certain procedures that are not performed by a physician.

State regulations

As discussed in the federal regulations concerning APPs, state regulatory bodies control what services a health care practitioner can provide. This varies from state to state, but in the state of Georgia, for example, the state medical board oversees the regulation of PAs and the state nursing board oversees the regulation of NPs. Therefore, it is imperative that physicians acquaint themselves with the regulations for APPs in their state of practice. We encourage urologists who are considering expansion of his or her practice to include APPs to review the guidelines for their state of practice to best understand the scope of practice for APPs.

Each state law varies on scope of practice issues. The state practice acts generally outline these four areas: independent practice, practice under the supervision of a physician, independent practice with a collaborative agreement, and independent practice without a collaborative agreement.

Several resources practices might find helpful to identify state requirements:

American Academy of Physician Assistants (login information required)
American Association of Nurse Practitioners (login information required)
American Medical Association (login information required)
American Medical Association: Physician assistant scope of practice (by state)
Barton and Associates NP Scope of Practice Laws
Barton and Associates PA Scope of Practice Laws

Coding for APPs

It is imperative that practicing urologists become acquainted with codes regarding a specific procedure or service to fully understand how best to utilize the services of APPs. A quick guide to the allowed requirements per service can be found in the AMA Current Procedural Terminology Manual,²⁷ which is commonly known as the AMA CPT book and can be found in most urology offices.

As an example, we will use the urodynamics codes (51725-51798). The AMA CPT book states the following: “All procedures in this section imply that these services are performed by, or are under the direct supervision of, a physician or other qualified health care professional and that all instruments, equipment, fluids, gases, probes, catheters, technician’s fees, medications, gloves, trays, tubing, and other sterile supplies be provided by that individual.” Thus, in regards to urodynamic studies, physicians and APPs are allowed federally to perform these services if the state regulatory body allows it, and the physician does not have to provide direct supervision.²⁷

Although CPT provides guidance on CPT descriptors and how to report certain codes, insurers provide additional guidance on what is required when reporting levels of supervision. Medicare provides guidance on Incident Only Services in its Medicare Learning Network (MLN Matters).^{18, 28}

It must be clearly understood that if the physician does not provide direct supervision, the procedure must be billed under the APP’s NPI number and Medicare reimbursement will be 85% of the Medicare allowable fee²⁹ (refer to the Medicare Physician Fee Schedule [MPFS]). The billing of the service for non-Medicare patients is determined by contractual agreements with private insurance companies.

Pateint perceptions of APPs

Limited comparisons exist among the quality of care provided in surgical clinic environments between physicians and NPs, physicians and PAs, NPs and PAs, or between physicians, NPs, and PAs. Many of the studies that have been published to date evaluate the success of APPs in primary care settings or in specialty care settings such as diabetes management. Recent works consistently cite “legacy” studies completed prior to 2000, but many of these studies have not been repeated and lack both comparable patient satisfaction and quality-of-life metrics. Further, results may not be applicable to contemporary medico-legal and insurance environments that reflect the practice expansion of APPs. Groups such as the American Academy of Family Physicians have cited online poll data from 2013 that indicate that physicians are the preferred care provider, according to patients, when asked to choose between a physician and NP.³⁰ However, the survey population was significantly skewed towards higher socioeconomic status and politically engaged registered voters. No other national groups have attempted a similar survey. Nonetheless, trends in peer-reviewed literature suggest that additional insight into potential roles for APPs within surgical practices such as urology are needed.

Hooker, Cipher, and Sekscenski investigated the experiences of 146,880 randomly sampled Medicare beneficiaries with generalist physician, NP, or PA care.³¹ In this study, 3,770 respondents identified a PA or NP as their personal health provider. Data were collected with the Consumer Assessment of Health Plans Survey (CAHPS), a 92-item standardized instrument. The distribution by type of provider for patients in fair or poor health was similar among the three groups, with 30.5% being cared for by a physician, 33.3% a PA, and 38.7% an NP. The distribution across the four measured satisfaction domains on the CAHPS was similar across the three groups, demonstrating a small effect size (Cohen's D < 0.20). The authors concluded that the study supports previous findings that patients are generally satisfied in their primary health care setting regardless of the provider. These authors suggest that further study should link patient satisfaction and treatment outcomes among all three provider groups with specific diagnoses.

Resnick and colleagues used a 12-item, anonymous, nonvalidated electronic survey of surgical residents to gauge the status of the use of nonphysician providers in their surgical departments.³² A similar nonvalidated survey was administered to the nonphysician providers at the same facility. Respondent rates were 50% for residents and 45% for APPs. Notably, 91% of the resident respondents agreed or completely agreed with the addition of APPs to their service, but only 41% agreed or completely agreed that they understood the role of the APP. These authors concluded that the addition of APPs did not adversely affect time for operative experiences or exposure to clinical care. Results among the APPs were mixed, with some commenting that they did not feel that their educational goals and job requirements were sufficiently delineated from those of junior residents.

Larkin and Hooker looked specifically at comparisons between emergency medicine residents, NPs, and PAs working in the emergency departments (EDs) of three urban teaching hospitals.³³ Data were collected via a survey instrument that had established face, construct, and test/retest validity and was specifically designed with three independent clinical scenarios to address this specific research question. Patients were willing to see APPs for minor injuries, but preferred to see residents as the clinical scenarios became more complex. Four out of five patients expected to see a physician in the ED, but were interested in knowing if there was a cost difference among provider types. The results demonstrated support for previous studies that have shown that as complexity of care increases, patient satisfaction with seeing APPs declines. Patients were more willing to see a PA if they were female, but there were no statistically significant predictors of patient willingness to use an NP or resident. Overall, results demonstrated that patients were more willing to see resident physicians than nonphysician providers for emergency care, especially in the context of a time delay for care. The authors admitted that these were unexpected findings and reflect the results of older studies from the 1970s; it also is congruent with studies from the 2000s reporting that a higher percentage of patients seen by physicians would return to physicians for care.

Residency programs in general surgery and orthopedics surgery have long been established for more advanced training and surgery for PAs. While patient satisfaction is often reported in studies of PAs in surgical subspecialties, validated studies that indicate the reason behind the high patient satisfaction have not been conducted.

Kaiser Permanente Study

A study conducted in 1995 by Kaiser Permanente Northwest (KPNW) attempted to evaluate patient satisfaction with care managed by different provider types, including PAs, NPs, CNMs, and physicians.³⁴ Questions were mailed to members of KPNW who visited five different types of medical practices, including internal medicine, family practice, pediatrics, obstetrics/gynecology, and orthopedics. Specific questions utilized from the Art of Medicine survey are listed below:

How COURTEOUS and RESPECTFUL was the clinician?
How well did the clinician UNDERSTAND your problem?
How well did the clinician EXPLAIN to you what he or she was doing and why?
Did the clinician USE WORDS that were easy for you to understand?
How well did the clinician LISTEN to your concerns and questions?
Did the clinician spend ENOUGH TIME with you?
How much CONFIDENCE do you have in the clinician's ability or competence?
OVERALL, how satisfied are you with the service that you received from the clinician?

The first objective was to explore differences in patient satisfaction with physicians and nonphysician providers. The second objective examined the attitudes of the patients of three types of providers to see if previous observations were supported by a large-scale study. Overall satisfaction was reported by 89% to 96% of patients of PAs, NPs, CNMs, and physicians. The authors concluded that patient satisfaction appeared to depend on communication style regardless of provider type. The authors concluded that the decision to incorporate PAs, NPs, and CNMs into medical practice has gained patient acceptance.

In a 2013 study, referrals from physicians, NPs, and PAs were blindly evaluated to examine differences within the specific context of patient complexity.³⁵ These were referrals to the Mayo Clinic Department of General Medicine, which reports that approximately 10% of referrals from primary care practices are submitted by NPs and PAs. While the overall quality of referrals was suboptimal, there was no statistically significant difference in the complexity of patients referred. However, patients referred by physicians were older and more likely to be men. The primary difference reported by authors was that referrals from physicians more often had a clearly articulated reason for referral and more complete clinical information, and the blinded review determined that MD documentation supported a better understanding of the pathophysiology involved. Only 3 of the 44 responding NPs and PAs indicated that they “always” discussed referral plans with SPs. The authors suggested that their findings support the need for increased research on the abilities of NPs and PAs to individually manage patients with complex problems in a primary care setting. They go on to suggest that multidisciplinary teams that include NPs, PAs, and MDs can provide excellent care in many environments by focusing on a team-based approach. The authors also point out that within the context of the changing health care system, there may be a need for guidelines regarding best practices for collaboration within any team that includes NPs, PAs, and MDs.

Integration of APPs into practice

Although APPs can help to offset the workforce shortage facing urologists, the potential for disruption of the educational ecosystem for urology residencies must be considered at academic centers.

Academic practices

The ACGME states that physicians should be trained to engage in clinical activities with other health care providers. More widespread utilization and incorporation of APPs in academic centers will help fulfill this. In fact, APPs enhance the educational value of rotations for residents in addition to decreasing residents’ workload.³⁶

The integration of APPs into academic medical center (AMC) practice was studied to examine care delivery performance measures and financial support.³⁷ A structured, three-part survey developed for this study assessed the role of organizational demographics, level of resident substitution, and perceived value of APPs within these academic systems. The survey included open-ended questions and assessed the AMC characteristics regarding integration of mid-level providers. The average ratio of APP to physician ranged from 1:3.7 to 1:18.5 in 26 surveyed institutions, which were clustered in the Midwest and East Coast. These AMCs used APPs for most services, including outpatient clinics, primary care, and surgical environments. In this study, 81% of the facilities reported that APPs function as resident substitutes, with substitution up to PGY-4, although some facilities did not detail the equivalent level of functioning for their APP population. A total of 18 AMCs did not document the financial impact of APP practice, and others reported varying degrees of financial awareness relating to APPs. Patient satisfaction metrics directly related to APPs were not tracked; instead, metrics were usually tracked based on the specific service (e.g., internal medicine). Overall, AMCs reported that the primary reason for maintaining APPs was to meet ACGME requirements and to improve patient throughput.

Community Practices

Newhouse and colleagues performed a systematic review of APRN outcomes from 1990 to 2008, including a search for data regarding all four APRN groups, acknowledging that no systematic reviews of CNSs or CRNAs had yet been published.³⁸ They reported on 37 studies that examined patient outcomes by NPs directly compared with care managed exclusively by physicians. A high level of evidence supported equivalency between the care provided by NPs and that of physicians in the areas of patient satisfaction, self-reported perceived health, functional status, glucose control, blood pressure control, ED/urgent care visits, hospitalization rate, length of stay, and mortality. Only in the context of lipid management was the care provided by NPs better than that of physicians. The authors concluded that APRNs/NPs should have an expanded role in health care and be incorporated more fully into patient management, including expansion into more specialty settings.

In many nations outside of the United States, APPs have been established as cost-effective and safe health care providers who improve health care access. Although this has not been yet established in the United States, this country has similarly demonstrated both a decrease in the ratio of physicians to the population and an increasing need for medical services.³⁹

APPs in urologic practice

Few studies have specifically examined the success of incorporating APPs into surgical subspecialties. This may reflect a more recent trend of recognizing the potential cost-effectiveness of incorporating APPs into surgical specialties as well as an acknowledgement born of necessity with the reduction in resident work hours as required by ACGME. Robles and colleagues offered a case report discussing the successful integration of an NP to team of three colorectal surgery attending physicians.⁴² They reported a 52% reduction in ED visits after the NP was hired, as the NP was able to successfully triage and manage many patients over the phone, either by recommending a clinic visit or by providing appropriate management. These authors concluded that the addition of an NP to their practice provided improved patient support post-discharge and resulted in significant cost benefit.

However, a review by the Department of Veterans Affairs was not strongly in favor of APP use, and strong conclusions or policy changes relating to extension of autonomous APRN practice were not established on the sole basis of the evidence. Although no differences in four outcome measures (health status, quality of life, mortality, hospitalizations) were detected, the evidence cannot rule out the possibility of differences due to a small body of evidence regarding health outcomes of patients receiving care from an APP.⁴³

The role of the APP in a urology practice is highly variable and dependent on the needs of the practice. Some APPs may be used exclusively in the operating room in a first assisting capacity while others see general urology patients independently at small satellite clinics and refer more complex cases to their SP. At one practice, an APP may work exclusively in survivorship clinics, while at another, APPs may manage inpatients and share overnight call. Furthermore, the role of an APP may evolve into a broader scope over time as trust between the APRN or PA and the SP strengthens. Reevaluation of the scope of practice of an APP is necessary as the APP develops more advanced knowledge of urologic conditions or as the needs of the practice change.

The use of an interprofessional ward team incorporating APPs has been shown to be feasible. Such a team optimizes the service-to-education balance and exposes learners to a collaborative clinical environment, enabling residents to both interact with APPs and appreciate the value that they provide.⁴⁴

Canon and colleagues acknowledged the need for a changing model for pediatric urology and discussed the development of their practice model. Their model included pediatric NPs working directly with pediatric urologists throughout the care continuum, from admissions to inpatient orders and discharges.⁴⁶ An outpatient care team, including an NP, managed routine clinic cases, completed postoperative evaluations, and managed nonsurgical urologic disease in children. This model successfully increased the number of pediatric urology patients treated without the addition of a full-time or part-time pediatric urologist, supporting another study that reported that 30% of pediatric urology patients could be effectively managed by APPs with appropriate training and experience.⁴⁶ These authors reported that their model of care allowed pediatric urologists to focus on cases that were most in need of physicians’ specialty training and skills. They also reported that their pediatric NPs underwent an orientation period of several months specific to either the inpatient or outpatient setting.

The AANP supports the role of the NP as part of cost-effective, team-based care, consistent with the recommendations of the IOM.⁴⁷ This guidance acknowledges the patient as the center of the health care team and encourages all members of the team to perform at their full potential. The AANP endorses a role for the NP as one that supports a systems approach to care delivery and promotes cooperative partnerships among patients and health care providers.

Multiple sources^{6, 48, 54, 55} have cited the consistent, high-quality care that can be provided by APPs. A review of the literature demonstrates that there is clear potential in a role for APPs in patient management, evidenced by the sustained number of APPs that graduate each year. Further, APPs are an unrecognized resource in the clinical management of patients within surgical specialties. With clear job descriptions, role delineations, and expectations, specialty practices can successfully incorporate APPs into patient care. APPs can provide consistent, reliable care that can lead to reduced use of the ED and higher patient satisfaction with care, especially postoperatively.

APPs performing procedures

Medicare claims data between 1994 and 2012 have demonstrated a dramatic increase by several thousand percent for many commonly performed procedures. This relatively unbridled exponential increase suggests that there is a need for increased healthcare supports and more service providers. The formalized education and training of APPs can help to relieve this ever-increasing burden.⁴⁰

The proportion of cases assisted by APPs rose significantly for all major urologic procedures in a study period from 2003-2014. While this increased utilization does help to address the workforce shortage,⁴¹ many surgeons feel that that the paltry fee (<20% of the primary surgeon rate) they are reimbursed as an assistant is not worthy of their time commitment in the OR and that their time can be more effectively utilized in other clinical activities.

The 2018 AUA census⁴⁵ data show that APPs are performing procedures such as circumcision, cystoscopy, hydrocele aspiration, intravesical Botox, prostate biopsy, Testopel injection, and vasectomy. The most common procedures are cystoscopy and Testopel injection. Other procedures that APPs might be trained to perform include percutaneous tibial nerve stimulation (PTNS), difficult bladder catheterizations, and urodynamics.

Just as the “core competencies” describe a process of grooming a newly graduated, or new to urology, APP into a skilled practitioner who can independently manage a wide variety of urologic conditions, the same training methodology can be applied to procedural skills competency. In the initial phases of learning a new skill, an APP should be expected to understand the scientific foundation and necessity of a specific procedure and observe several procedures performed by an experienced mentor. A period of observation is required once the APP begins performing hands-on procedures. When the APP has demonstrated an appropriate level of aptitude, the APP should be expected to perform procedures independently but be encouraged to (and be able to) ask for help if they are uncomfortable in a particular situation. Technology should be used when possible to assist with the comfort level of the APP and the physician. For example, still or video images taken during cystoscopy can aid in the subsequent review of the procedure by the APP and SP.

While each APP should progress through the skill levels of various procedures to a goal of competence, it is difficult to quantify how many patient encounters or how much time the training may require. APP competency in a procedural skill is dependent upon several factors, including the clinical environment, number of patient encounters over a given time, prior clinical experience of the APP, and in some cases, gross and fine motor skills of the APRN or PA.

APPs can play a vital role as part of the health care team. Interventional radiology and gastroenterology are examples of medical specialties that have adopted guidelines and have data on APPs performing procedures. However, a paucity of research remains regarding the best practices for procedural skills training, patient safety in procedures performed by a physician vs. an APP, and procedure-specific patient satisfaction. These are areas that should be studied as APP practice and optimal team integration continue to be areas of interest.

Office procedures

There is mounting evidence regarding the increasing role of the APP in performing urologic procedures despite the lack of existing formal training, guidelines, or curriculum.

Quallich surveyed 53 NPs to evaluate tasks critical to the role of NPs in urology. Of the respondents, 26 reported performing urodynamics, 15 performed surveillance cystoscopies with 10 of those performing biopsy, 13 performed prostate biopsy, and 11 performed vasectomy.¹⁰ In 2015, Doran and colleagues reported a significant increase in the performance of urologic procedures by both PAs and NPs through evaluation of CPT codes, national Medicare Part B beneficiary claims, and Physician Supplier Procedure Summary Master Files with dates ranging from 1994 to 2012.⁴⁸ In this review, cystoscopy increased from 24 to 1,820, transrectal prostate biopsy increased from 17 to 834, complex indwelling urinary catheter placement increased from 471 to 2,929, urodynamic testing increased from 41 to 9,350, and renal ultrasound increased from 18 to 4,500. In another study, Langston and colleagues found that of 296 APPs surveyed (62% NP), 81% were performing procedures independently, with 63% of those procedures being described as complex in nature.⁸

Studies that have evaluated the current use of APPs for urologic procedural care have suggested that the percentage of clinical procedures performed by APPs without direct supervision (i.e., billed to insurance using a modifier) continues to increase. A study by Erickson and colleagues found a nearly 24-fold increase (from 0.05% to 1.3%) in the percentage of cystoscopy with ureteral stent pulls from 2003 to 2014 performed independently by APPs. These data were recently updated (Figures 1 and 2) for this publication, revealing that these percentages continue to increase, especially for less invasive procedures such as pessary insertion (13.52%), suprapubic tube change (14.04%), and simple catheter placement (14.88%).⁴⁹ Importantly, when the AUA directly asked APPs about their independent procedural practices in 2017, bladder instillations (56.3%), intracavernosal injections for erectile dysfunction (55%), urodynamics interpretation (40%), tibial nerve stimulation (39%), and chemotherapy injections (34%) were most commonly cited as procedures that APPs perform (and bill) on their own.⁸ By the AUA APP Census data, more than half of the PAs and NPs independently perform intracavernosal injections for ED and bladder instillation and nearly one in five APPs assist urologists in performing cystoscopy for difficult catheter placement (19.2%) and stent removal (19.2%).⁹

Figure 1. Independent performance of clinic procedures by APPs

Figure 2. Percentage of urologic clinic procedures performed by APPs by year

No nationally accredited training programs currently exist for NPs, PAs, or MDs to learn procedures such as flexible cystoscopy⁵⁰ despite the fact that regular use of this procedure has been utilized in the outpatient setting for nearly 40 years.⁵¹ Barriers such as this will continue to hinder diagnostic and therapeutic skills acquisition for urology APPs,⁵² but Quallich and colleagues have recently proposed a standard cystoscopy training program for APPs.

Variations in NP education, being unfamiliar with the laws governing scope of practice, acquired specialty skills, liability concerns, and anxiety over competition are strong deterrents for urologists in the utilization of NPs for performing procedures in a practice.⁵² For some NPs, a concern may also exist in the form of state nursing boards that require evidence of training or certification for specialty skills and procedures in urology. Collaboration between APPs and urologists to design formal educational training and credentialing programs for practice and procedures may enhance the team-based approach to care as advocated by the National Academy of Medicine.⁵³

Compensation for APPs

APPs continue to represent an increasing percentage of the US health care workforce, with continued integration expected both due to necessity and ongoing projections for NP and PA profession growth. Hooker, Brock, and Cook reported that by the end of 2013, more than 201,000 APPs were employed in clinical practice in the United States, representing approximately 20% of the health care workforce who function as care providers and medication prescribers.⁵⁶ Data for their survey were not specifically collected to reflect most subspecialties, but 21.3% of PAs reported a surgery employment environment (similar data were not available for NPs). Auerbach, Staiger, Buerhaus reported an overall growth projection of 1%, through 2030, for full-time equivalent physicians as increased retirement rates are offset by increased entry of physicians into the workforce.⁵⁷ In contrast, the projected growth through 2030 is 6.8% for NPs and 4.3% for PAs.

Overall, nearly 40 percent of APP members of the AUA made more than $115,000 in 2018, higher in PAs (49.4 percent) and lower in NPs (32.8 percent).⁹

NPs working in specialty settings are typically supervised by, or collaborate with, the specialist, resulting in a baseline higher salary simply due to the fact that specialists traditionally earn more than primary care providers. This wage difference is not unique to nursing but rather inherent in the specialist-nonspecialist dichotomy. This difference in salary is likely to change with increased utilization of APPs performing procedures, predicted increases in reimbursement for outpatient procedures, and declining reimbursement for surgical services.

The State of the Nurse Practitioner Profession is the 8^th version of the National Nurse Practitioner Sample Survey (NNPSS).24 This survey reported that 95.2% of NPs hold a graduate degree and that 66.9% of the respondents were family NPs, with a total of 87.1% certified in a primary care discipline. In this survey, 14.5% of the respondents reported working in hospital-based outpatient environments, and 3.2% of respondents reported working in a surgical-focused area. NPs working in surgical environments reported a 2018 salary range of $96,000 to $126,000 with an average hourly rate of $60.72. NPs who self-reported a urology focus saw an average of 21 patients per day.

Li et al. performed a secondary analysis of cross-sectional data from the Department of Health and Human Services, Health Resources and Service Administration, and the 2012 National Survey of Nurse Practitioners.⁵⁸ They reported a clear difference between NPs working in primary care, with an average hourly wage of $43.70, and NPs in specialty care settings, with an hourly average of $47.20. While these authors did not specifically provide data for surgical settings, 70.1% of their sample reported having a specialty care place of employment. These authors suggested that the findings may be influenced by how NPs working in primary care are paid (e.g., 85% to 100% of physician fees) and that specialty practice NPs may receive higher compensation for working later shifts or weekends. This data was not broken down geographically.

Greene et al. reported that male NPs earned almost $13,000 more than their female counterparts. Fewer males worked in a primary care setting, with 15% of the male respondents working in surgical specialties, which may be a potential contributor to the salary gap.⁵⁶ This gap persisted despite statistically controlling for demographics, work type, work experience, and work autonomy. Based on the 2012 National Survey of Nurse Practitioners, NPs from racial and ethnic minority backgrounds earned $4,200 more than their Caucasian counterparts, independent of gender. More women have entered the PA profession and replaced retiring older men,⁵⁹ while the NP profession has remained consistently female.⁶⁰

The 2018 Statistical Profile of Certified Physician Assistants reported that 25.8% of certified PAs worked in primary care and 18.5% worked in a surgical subspecialty.⁶⁰ In addition, 40.5% of PAs worked in a hospital setting while 39.5% worked in an office-based private practice. In 2018, 78.7% of full-time practicing PAs were paid an annual salary, 17.5% received an hourly wage, and 3.8% were paid based on productivity either entirely or in combination with a guaranteed minimum base salary. The median salary for full-time practicing PAs was $106,000 while those receiving an hourly wage reported earning a median of $60 per hour. PAs compensated using a productivity-based model reported a median salary of $150,000, but across the full profession, median compensation was $107,500.

The AAPA publishes an annual salary report describing the demographics and compensation of PA practice based on direct survey of the membership and data collected from the National Commission on Certifying Physician Assistants (NCCPA). According to the AAPA 2019 Salary Report, PAs working in urology reported a base salary ranging from $89,000 to $135,000 with productivity bonuses ranging from $1,000 to $25,000.⁶¹ Interestingly, PAs practicing in primary care reported base salaries ranging from $84,000 to $128,250 with productivity bonuses ranging from $1,000 to $30,000. This 5% to 6% difference in base salary and 20% difference between primary care and surgical subspecialty is not comparable to the 44% average salary difference reported between primary care physicians and specialists.⁶² The discrepancy in salary between primary care and surgical subspecialty PAs can be attributed to a number of factors unique to individual practice settings and the variable utilization of PAs in a urology practice.

Compensation models

Compensation models in urology practices can take various forms. Multiple factors contribute to the variability in specialist APP compensation models, including, but not limited to, practice setting (academic vs. private), clinical work hours, market salary data for the surrounding community, facility budgets, relative value units (RVUs), net collections, incentives, gross productivity, and distribution of overhead. Increased use of APPs and variable utilization practices combined with an emerging emphasis on value-based models for APP compensation have encouraged the development of compensation models uniquely suited to the practice. However, standardized compensation models for the APP workforce have developed more slowly than those for physicians partly due to the productivity calculations including wRVU’s for APPs are more difficult with utilization “incident to” billing assigned to physician providers.

Straight salary is the most common compensation model for APP member of the AUA (53.0 % in PAs and 43.1 % in NPs).⁹

Urology practices are challenged with developing compensation models that are attractive to prospective APPs, acknowledging the significant impact on recruitment/retention of APPs.

A vast majority of AUA APP members reported their practices track their productivity, 91.7 percent for NPs and 83.8 percent for PAs.⁹

Additionally, both academic and private practices must determine a mutually satisfying compensation strategy in which the APP productively supports the practice in a manner that is not in direct competition with the physicians in the practice.

When determining potential APP compensation, each environment must determine what drives the team-based care. This could include issues such as quality care, appointment access, patient education needs (e.g., support groups), and care coordination across outpatient, inpatient, and rehabilitation facilities and home-based care. Historically, many organizations have not implemented an RVU-based model of APP compensation, but that is beginning to change. There are four basic payment methods to consider when establishing compensation:

Annual base salary: paid to perform a particular role based on job description
Annual base salary plus productivity bonus: salary guaranteed, plus additional compensation based on a predetermined formula calculating an agreed upon amount of a set threshold of billed charges or net receipts
Percentage of net receipts: compensated based on amount billed minus accounts receivable minus overhead
Hourly rate: compensated solely for hours worked

Several recommendations for calculations to determine the worth of APP service have been proposed. One such recommendation suggests that APP value can be roughly based on the physician relative value scale: 48% overhead cost, 4% malpractice costs, and 48% cost for service.⁶² Recommendations to project an APP salary include:^{63, 64}

Calculate income based on APP anticipated billing
Subtract 10% for unpaid bills
Subtract practice expenses (can be 20% to 50% of earnings)
Subtract any required physician consultation fees mandated by state licensing laws (possibly 10% to 20% of earnings; not all states require this and it varies nationally and is negotiated among providers)
Subtract a percentage for employer profit (can be up to 15% to 20% for private practice)

Additional factors considered in an APP compensation package may include the following, with the understanding that many will be influenced by practice, regional, or community standards:

Benefits offered to physicians/surgeons
Signing bonus
Compensation/allowance for CME (including allowance for airfare, room, and food for at least one national conference)
Continuing education time as a paid benefit vs. need to use vacation time
Retirement plan
Health plan/vision plan/dental plan
Compnay provided cell phone and/or pager
Car allowance
Vacation time (at least 3 to 4 weeks)
Sick time/personal days (usually 1 to 2 days/month)
Disability insurance
Employer-covered malpractice
Empolyer-covered cost for Drug Enforcement Agency (DEA) license
Payment for professional certification/license
Compensation strategy for on-call time (when applicable)
Compensation for hospital utilization (inpatientround/consults)

As a general rule, subspecialty-trained APPs are compensated at a higher rate than their primary care counterparts, but, similar to physicians, geographic differences in salary rates, payor mix, practice needs, and individual APP compensation goals will often determine the most suitable compensation strategy for the APP and the practice. For example, an individual APP may place a higher value on income and bonuses than vacation time.

APPs in the outpatient setting

A vast majority of NPs see office patients as part of their clinical responsibilities.

Both PAs and NPs who completed the AUA census see a median number of 60 patients per week, and reported spending a median number of 40 hours on clinical duties and 5 hours on non-clinical duties per week.

Nearly two thirds of APP AUA members have a dedicated medical assistant (MA) or nurse (RN or LPN) to support them when they see patients. PAs are more likely to be supported by a dedicated MA while NPs are more likely to be supported by a dedicated nurse.

Compared to NPs, PA AUA members are more likely to do post-operation evaluation, do procedures in the outpatient setting and perform pre-operation evaluation while also seeing patients in office.

AUA census information also reported 34.1 % of PAs and 28.3% of NPs work in four or more office locations. On average, about two-thirds of APPs work in more than one location.⁹

APPs in the inpatient setting

The role of APPs in the inpatient arena continues to evolve, and the full impact of the increasing APP presence in inpatient roles on urology has yet to be studied, including APP influence on patient safety, revenue, and urology education. Some AMCs have instituted programs in which APPs are responsible for a majority of inpatient management and the discharge process. This shift has occurred due to resident work requirements and AGCME restrictions.

In nonacademic institutions, APPs may also provide inpatient consultations. However, this can be controversial. When physicians request urology consultations on inpatients, the expectation may be that this service is performed by a urologist. However, in many circumstances, the APP may have been the first point of contact and performed the initial history, examination, and assessment. This can greatly streamline the process of inpatient evaluation and, if the APP is employed by the urology practice, the consult can be billed at 100% according to the MPFS after conferring with the urologist.

Inpatient procedures performed by APPs cannot be billed by supervising or employing physicians and instead must be billed under the APP’s own National Provider Identifier (NPI) number at 85% of the MPFS rate. If supervision is required for the procedure, it can then be billed under the physician's NPI number for 100% of the MPFS rate. (Refer to the Appendix for more billing examples.)

Eaton et al. surveyed attending surgeons and surgical teams at an urban tertiary referral center that also employed service-based APPs.⁶⁵ While this did not include urologists, the survey did include emergency, general surgery, transplant, and minimally invasive surgery specialties. Most attendings had been in practice for more than 15 years and acknowledged that in order for residents to gain sufficient surgical skills, some basic patient care tasks have to be forfeited and completed by service APPs. Respondents acknowledged that APPs can be extremely skilled at managing patients, but that there is wide variation in clinical expertise. Respondents generally acknowledged that having inpatient APPs as part of their service provided a significant return on investment and decreased the faculty and resident workload. However, survey participants also acknowledged that the efficiency and skill level of APPs may detract from resident training, as attending surgeons may be more likely to communicate directly with an APP employed as a constant person on their service. Approximately 30% of PAs and 24% of NP AUA members take after-hour calls as part of their employment requirement.⁹

Adding APPs to inpatient critical care teams improves efficiency and outcomes. However, as most urology patients are not exclusively managed by critical care teams, it can be challenging to extrapolate this success to APPs managing lower acuity inpatient or observational overnight stays. To date, there has been no study exclusively dedicated to the impact of the APP role on urology inpatients.

Malpractice and the APP in urologic practice

Liability statistics

Urologists unfamiliar with the utilization of APPs may be concerned with exposing their practice to additional liability risk with the addition of such practitioners. The delegation of responsibility to APPs requires relaxing control over the doctor-patient interaction, which may introduce uncertainty over the care that may have been provided and the potential for harm and subsequent legal action by the patient. A review of archival data on liability actions from various repositories reveal that the absolute incidence of legal action involving APPs is minimal compared to actions involving physicians.⁶⁶ Nonetheless, there has been a rising trend of legal action, in particular against NPs, which raises some concern but is at least in part reflective of the increase of their presence in the workforce.

The National Practitioner Data Bank is a federally required repository of claims made against physicians and other licensed health care practitioners. A study of trends of this database from 1991 to 2007 revealed a total of 320,034 liability reports.47 In contrast, the number of reports for PAs was only 1,535 and the number for NPs was similarly low at 2,715. Miller evaluated the more recent trends of the same database and observed that from 2007 to 2010, the annual number of liability allegations against NPs increased 18% from 270 to 327.⁶⁷ CNA, a major liability carrier for NPs, published an analysis of its claims data from 1995 to 2003 and found a total of 368 actions from 1994 to 2002, a rise from 3 per year to 53 per year.⁶⁸ An analysis of claims made against PAs in the state of Colorado from 2002 to 2009 identified only 34 actions.⁶⁹ From 2007 to 2010, the most litigious states for NPs were, in descending order, Florida, Washington, Alabama, New York, California, and Massachusetts.

In Hooker’s analysis of the National Practitioner Data Bank from 1991 to 2007, the most common reasons for liability claims against PAs were diagnosis and treatment, accounting for 80% of claims.⁶⁶ Less common reasons were medication and surgery. A reversal in trends has been observed for NPs. Initially, in the period from 1991 to 2007, the most common reasons for claims were anesthesia, obstetrics, and diagnosis, which accounted for 75% of claims, and treatment and medications were less common. However, from 2007 to 2010, the leading reasons for claims were diagnosis, treatment, and medications, with only about 10% of claims relating to obstetrics and monitoring. Regarding the severity of the claims, more recent trends reveal that almost half of the injuries ascribed to NPs were deaths. Slightly more than one quarter of the remaining injuries were classified as “significant or permanent.”⁶⁷

From 1991 to 2007, a total of $74 billion was paid out due to liability claims. Awards against PAs represented only 0.003% of this total. Similarly, claims against NPs represented only 0.007% of the total. An NP is 24.4 times less likely to incur a liability payout than a physician and a PA is 12 times less likely. According to the data bank, the payout amounts per award were similar for physicians ($308,383) and NPs ($306,310), but about 25% less for PAs ($232,066).

Strategies to reduce risk

Although the number of liability actions through 2010 has been, in absolute terms, very modest for PAs and NPs, many physicians postulate that as the number of APPs rapidly increases and as their scope of practice increases, there may be a significantly greater number of lawsuits. SPs and other employers are routinely named in lawsuits along with an APP under his or her supervision. In some cases, the physician can be held solely responsible under a legal concept known as “respondent superior (let the master answer).”^{69, 70} Supervisory culpability may extend to an NP who is an independent contractor under a legal concept known as “borrowed servant.” In some cases, the physician or employer can be held liable for “negligent hiring or selecting” if the NP is shown to have an unsatisfactory background.⁷⁰

Understanding the risk factors that lead to legal action may allow urology practices to increasingly engage the services of APPs without jeopardy. As with physicians, most lawsuits can be traced to a breakdown in communication. Detailed protocols, careful documentation, and open channels of communication are essential to avoid patient harm. In many ways, APPs may improve patient experience and satisfaction and diminish the inclination of a patient to sue by virtue of the greater time they are often able to spend with patients taking histories, providing education, and establishing rapport.

Physicians must notify their liability carriers when they hire an APP. The additional premium is usually minimal, and it is a shared limit (such as the standard physician liability limit of $1 million per lawsuit/$3 million total for all lawsuits). In many cases, APPs will carry their own individual liability policy. Individual policies allow them to maintain coverage if they change practices along with value-added services such as legal fees for disputes with the state involving licensure.

PAs: specific considerations

Specific legal action items mitigate a PA’s potential risk for exposure to liability claims. Some of these may be more specific than others to California, which is home state to the author. All PAs are required to have a written Delegation of Services Agreement that must be signed and dated by the SP. Failure to do so has resulted in disciplinary action and stronger liability suits. If the PA provides services with more than one SP, there should be different agreements that reflect such variations. Written emergency backup procedures, a list of services the PA is authorized to perform, a list of medications that the PA is authorized to administer, and written order sets should be available. Any limitations on the PA should be documented as well.⁷¹

Satisfactory supervision of a PA from a legal standpoint may be satisfied by different configurations. (Note: the following are specific to California; check your state’s requirement.)

The patient is examined by the SP on the same day that care is provided by the PA.
The SP countersigns and dates all medical records writen by the PA within 30 days of the care provided by the PA.
Most commonly, protocols govern the diagnosis and management of patients and must include the presence or absence of symptoms, signs, and other data necessary to establish a diagnosis or assessment. Protocols also specify any appropriate tests or studies to order. Medication recommendations and patient education are included. Details of informed consent for procedures as well as preparation for and technique of any procedure that is to be performed are included. Follow-up care is also included in protocols. These protocols do not necessarily have to be written out and may reference texts if those texts are readily available to the PA (including on the internet). When protocol supervision is employed, the SP must sign 5% of charts within 30 days of care.⁷²

Conversely, PAs should maintain careful documentation of their communication with the SP, including any examination results by the SP and all consultations. In many cases, a consulting physician will not document in the chart unless they evaluate the patient, yet they have provided a form of supervision and it is important for the PA to document this as such. This can provide the best defense against allegations of inadequate care. The PA should address all patient complaints in the diagnosis, treatment, or follow-up documentation. All laboratory studies and diagnostic test results should be initialed and dated. If no action is taken on laboratory results outside the normal range, an indication of the reason why as well as the signature of the SP can be important. Documentation should be completed within 24 hours of patient care; the courts view this as more reliable document from the standpoint of accurate recall of information.⁷²

Employers must be diligent in hiring and verifying credentials. Reducing liability for the acts of the PA begins with PA selection. SPs should verify the education, licensure, and status with the state medical board. Criminal background checks, due diligence on references provided, and job references from the last place of employment are also important.⁷¹ PAs must maintain their skill set and knowledge to reduce the SPs’ risk of vicarious liability. SPs should consider providing CME allowances. Liability insurance for SPs and PAs should address both joint and separate liability because SPs can be included in litigation aimed at PAs. Nonetheless, the trend in courts is to hold PAs and NPs independently accountable to the community standards as opposed to holding the SP accountable.⁷²

There is increasing scrutiny by state and federal governments into fraud and abuse, which is particularly relevant to the “incident to” status of claims to Medicare for payment. The SP is required to see the patient on the patient’s first visit and must be in the office at the time of the PA visit. Anti-kickback statutes prohibit payments or rewards from referrals from others. Therefore, referrals to the SP must not originate from the PA with the exception of in-office ancillary exemptions such as radiation, oncology, or imaging.⁷²

NPs: specific considerations

Unlike the mandatory supervisory role that physicians must adopt with PAs in every state but Mississippi, many states require physicians to work collaboratively with NPs. Some states may outline formal rules regarding physician accessibility, chart review, and conferencing. NPs may be mandated by state law to follow detailed clinical protocols and may even be subject to physician supervision in states such as Florida. The scope of practice of the NP varies based on state and is related to factors such as educational background, clinical experience, and collaborative relationships with physicians. The scope of practice of the NP is an important factor in a court’s decision regarding liability. Negligence may be evaluated in the context of whether the NP operated outside of his or her scope of practice.⁶⁸

Employers must be diligent in hiring and credentialing. Reducing liability for the acts of the NP begins with NP selection. The employers may need to consider the specific population focus of the NP and the intended patients the NP would be asked to manage (e.g., an NP certified in women’s health cannot legally evaluate adult male patients). SPs should verify the education, licensure, and status with the state medical or nursing board as appropriate. Criminal background checks, due diligence on references provided, and job references from the last place of employment are also important. NPs must maintain their skill set and knowledge to reduce the risk of liability, and SPs should consider providing CME allowances. Liability insurance for NPs may need to address both joint and separate liability, depending on the relationship with an MD that is required by the state, because SPs can be included in litigation aimed at NPs.

Under state nurse practice acts, regulatory bodies define the scope of practice for NPs and delineate requirements for licensure and exercise regulatory authority and disciplinary action. Regulatory bodies evaluate complaints, and a common cause for investigation is NPs prescribing controlled substances and other practices relating to pain management.⁶⁸

The overall incidence of malpractice is low for PAs and NPs. As these practitioners provide more care, the number of lawsuits will invariably increase, but the ratio may continue to remain low. Evidence-based analysis by Laurant and colleagues demonstrated that as more authority is transferred from physicians to NPs and PAs in the primary care setting, patient outcomes remain similar.⁷² Thoughtful and comprehensive protocols coupled with responsible oversight and open lines of communication can allow increasing participation of APPs with a minimal increase in risk. The greatest risk for malpractice arises when practitioners engage in practice beyond their competency base either because of a lack of protocol, disregard for protocol, or inability to secure adequate collaboration or oversight. It is also important to remember that in any given environment, APPs are held to the same standards of practice as physicians; there are no separate guidelines for care outcomes that apply only to APPs.

Disruptive technology and APPs

The use of APPs extends the number of patients for which a given urologist can provide care. Technology also extends the physician’s reach and efficiency. Patients have demonstrated a growing acceptance of APPs in urology after having become accustomed to their widespread presence in primary care and other surgical specialties such as orthopedics. Patients are also demonstrating acceptance of telepresent health care providers with favorable satisfaction surveys. New disruptive technologies, such as robotic telepresence and smart phone applications, provide patients with access to care in appropriate settings. The expanded incorporation of technology by allied health professionals in urology will decrease the number of urologists required to care for a given population, thereby addressing the existing manpower shortage. Telepresence also saves both time and money and improves patient access to urology care.

Most stakeholders—from the government to private payors to industry to patients—are motivated to lower expenses while increasing access. In primary care, APPs are perceived as more willing to work in underserved areas while costing less to provide, in many instances, similar services to physicians. The increase in the scope of practice of these allied health professionals is likely to continue, and urologists should consider how to best engage, educate, and train APPs in the physician-led, team-based care model.

The Robert Graham Center conducted an analysis of the distribution of primary care physicians in the United States.⁷³ Because physicians are not regulated in their location of practice, there is a preponderance of doctors in more favorable geographic locations, leaving the urban and rural areas of the nation with a significant manpower shortage. Estimates of the number needed to restore adequate coverage range from 6,500 to 20,500 physicians depending on the target one sets for population-to-physician ratios (2000:1 is the goal set by the Health Resources and Services Administration vs. the current national average of 1,485:1).

Access to care is critical, but the solution may not be producing thousands of more physicians and compelling them to live or work in areas not of their choosing. The access to care that a single physician currently provides may be amplified by disruptive technology, possibly allowing a physician to be remotely accessible to a rural or inner-city patient via telemedicine. Such telemedicine may include video link up, remote sensors, and microfluidics point-of-service diagnostics. With travel time eliminated, physicians can directly encounter more patients from various locations in a given day. Additional amplification can be provided by appropriate delegation of care to well-trained APPs who, with the same telemedicine technology, can incorporate robust algorithms of care that ensure safety and minimize physician oversight. This allows physicians to provide care to even larger populations. IBM’s Watson⁷⁴, or similar artificial intelligence technology, may derive these algorithms under the supervision of the physician.

Watson is now ubiquitously accessible in “the cloud.” In fact, initial patient history taking can be accomplished by Watson, which understands and communicates in English. Watson can not only provide a summary of the patient to the human provider, but also a recommended treatment. Further amplification of physician access may be derived from shared appointments, also managed remotely, with well-trained APPs. There will always be a need for some degree of hands-on contact during some patient evaluations, and this service can be provided with less expensively trained individuals who remain under telemedical supervision while providing a physical presence for assistance or a physical examination. Although urologists perform hands-on procedures in the office (e.g., vasectomies, cystoscopies, prostate ultrasound-guided biopsies, and urodynamics), some or all of these procedures may be delegated to highly skilled, well-trained APPs with the benefit of “store and forward” televideo technology when desired. Additionally, this teleurology presence provides consistent continued education for the APP for the understanding some urologic procedures.

Much of urology is cognitive, and for many patients, the extent of the hands-on requirement is genital or prostate examination, which also can be taught to APPs. More advanced surgeries will remain in the domain of the urological surgeon for now, and regional surgical centers staffed by dedicated urological surgeons and surgically trained APRNs and NPs can be allocated to meet population demands in a way that is less haphazard than current practice patterns. In current practice patterns, most urologists provide both office and surgical care, often with most care being delivered in the office. Advances in microprocessing, image recognition, haptic feedback, and robotics promise to eventually produce a true surgical robot.

APPs are also increasingly utilized as assistants in the operating room. In another study by Swanton and colleagues, the utilization of APPs in the operating room for major surgical cases was assessed using Medicare billing data by identifying cases that were assisted either by a second surgeon (CPT modifiers 80, 81, 82, 62) or by an APP (CPT modifier AS).⁴¹ Notably, second assistance for robotic cases by second surgeons fell by nearly 40% from 2003 to 2014 while assistance by APPs increased by more than 700% (Figure 3).

Figure 3. Annual rates of surgeon and APP assistance by procedure category

APPs are also being used to perform telemedicine. In a study by Sherwood et al, the use of telemedicine for triaging the urologic concerns of the state of Iowa’s male prison population was analyzed, showing that telehealth visits obviated the need for an in-person visit nearly 90% of the time.⁷⁵ Importantly, this decrease in health utilization did not affect the quality of care, and the group estimated that nearly 50% of the group’s problems likely could have been managed with telemedicine alone.

Although cost is the most politically pressing argument, the most scientifically compelling argument in favor of increasing utilization of APPs is quality outcomes. Laurant and colleagues demonstrated that expanding authority to APPs in the primary care setting resulted in no detriment to patient outcomes and satisfaction.⁷² Green and colleagues postulated that APPs could meet up to 70% of patient need in the primary care setting if allowed to practice to the limit of their training.⁷³ This number is reduced in specialty care, but evidence suggests a sizeable portion of patients whose urological care could be similarly managed.

Robotic remote presence technology

A key to maximizing patient outcomes under the care of APPs is satisfactory collaboration with and supervision by physicians. According to many state laws, collaboration and supervision may be provided off-site. However, a concern with remote supervision is the potential for compromised evaluation and decision-making. Telepresence platforms and remote sensing devices have been shown to result in the satisfactory transfer of information with no detriment to decision-making and outcomes. Currently, telepresence practice may utilize APPs or may rely on nursing staff or residents.

Currently deployed systems are configured as follows:

Bidirectional video on mobile cart
Secured VPN broadband connection
Recording/archiving capability
Split/multiple screens for multiple types of information
Well-informed practitioner attending to patient
Additional sensors providing data
Stethoscope, ultrasound, infrared, telemetry

These platforms are currently in use in intensive care units (ICUs), hospital EDs, postsurgical wards, and satellite clinics. Thus far, there has been an excellent track record of performance with equal or superior patient, doctor, and hospital satisfaction.

A randomized, prospective, multi-institutional study evaluated postoperative urology rounds using telepresence. A total of 270 patients at three institutions (UC Davis, Sentara Health, and Johns Hopkins) were randomized to postoperative rounds with an attending physician present or with a mobile telepresence platform. Surgeries included the following laparoscopic procedures: nephrectomy, partial nephrectomy, nephroureterectomy, retroperitoneal lymph node dissection, partial ureterectomy, and radical prostatectomy. Patients had an expected hospital stay of 24 to 72 hours. The number of postoperative complications, length of stay, and patient-reported satisfaction were monitored. Residents rounded on both arms and independently tracked and reported complications prospectively independent of and concomitant with the attendings’ evaluations. At the conclusion of the study, there was no increase in patient complications or length of stay. Patient satisfaction was investigated with a validated 21-item questionnaire including 9 questions specifically about the patient’s interest in incorporating the telepresence platform into their postoperative care. Compared to traditional, in-person rounds, patient satisfaction was similar or improved with telepresence, and two-thirds of patients preferred it. Patients commented that they felt that their telepresent doctors spent more time with them and were more available. Once the logistical obstacles of travel and competing office/operating room schedule were minimized by the telepresent platform, the attending physician could more flexibly devote time and attention to patient care, which was appreciated by the patients.⁷⁶

In urology, incorporation of a telepresent robotic platform provides both consultations and postoperative rounds to several rural hospitals without access to in-house urology specialists. In many of these hospitals, the ICU and some of the other specialties are similarly covered by telepresent physicians who work closely with the nurses and NPs present in the hospital.⁷⁷

Telemedicine experience defies preconceived objections that patients will not accept it because they desire the human touch and that doctors will not accept it because it does not allow for information that can only be ascertained from “being there” and because the complexity of the technology is a barrier to entry. Despite this, telemedicine is often considered a solution just for underserved areas. A review conducted in 25 centers using telerobotic presence in ICUs revealed a high degree of patient and physician satisfaction with the typical physician user being senior and often in an urban and academic setting.⁷⁸

A pilot program at a surgical ICU compared evening coverage utilizing telephone vs. telerobotic presence. With telerobotic presence, the hospital and ICU length of stay decreased, as did unexpected events. The time spent by the physician on rounds increased with telerobotic presence, as did the number of interventions, but subsequent calls decreased. Users reported a higher rate of satisfaction.⁷⁹

Inpatient medicine is not the sole domain of telemedicine. Outpatient diagnostic evaluations and patient instruction are successfully accomplished with telerobotic presence. Highly sophisticated neurotology evaluations have been conducted with the aid of an NP in outreach areas of post-Katrina Louisiana. The NP applies a video otoscope, infrared eye motion tracking goggles, and video laryngoscope to the patient. The information can be stored and reviewed later or can be transmitted and analyzed in real time. The ability to store and view information later allows for physician flexibility not only in space but also time. The key to a store-and-view strategy is a well-trained APP who can reliably acquire the needed images and data and who is able to adjust to variances appropriately. As with the ICU experience, patient satisfaction with telepresence neurotology evaluation was equivalent to in-person medical visits.⁸⁰ “Store and forward” recordings of cystoscopies performed by APPs and later reviewed by supervising urologists has proven invaluable in reducing backlog in patients awaiting hematuria workup at a busy Kaiser Permanente urology practice in San Diego, California.⁸¹

The capacity for remote telepresence training of inexperienced providers to perform complex tasks was demonstrated in a comparison study of outcomes of neuromodulation programming of neurostimulators as performed by experienced neuromodulation programmers vs. untrained nurses receiving instruction by telerobotic presence. The accuracy and clinical outcomes were equivalent, with high satisfaction expressed by patients, nurses, and physicians. The study group was inspired by their experience to work towards in-home neuromodulation.⁸²

In the future, examinations such as flexible cystoscopy and transrectal ultrasonography might be learned by an APP and then performed remotely with adequate telerobotic physician supervision. Technology can allow for remote control of the scope if desired and access to all monitors. Telesurgical platforms that are currently available can be utilized by urologists to increasingly guide APPs through procedures such as cystoscopy or prostate biopsy without being physically present. Such platforms allow live streaming of digital/visual information from one or more instruments, such as a cystoscopy, ultrasound, or fluoroscope while allowing simultaneous bidirectional telestration and conversation as well as an “in-room” perspective from a boom mounted camera.²

Telesurgical streaming can also allow APPs to virtually “scrub in” to surgeries on patients for whom they will be providing postoperative care to greater enhance their understanding of the patient’s risks and expectations for recovery. Such telesurgical broadcasts can be stored and edited for later review and teaching. Surgical broadcasts are also stored and evaluated by crowd source technology to provide valuable feedback for surgical skill set training.

Various telemedicine programs now exist in every state. Although the technology was initially aimed towards remote outreach, it offers several advantages for local care (Table 3).

Table 3. Advantages of telemedicine
Telemedicine involves multimodality communication between providers and patients as well as between providers to increase the transfer of knowledge. Advantages include the following: Telestration Texting/text chat PowerPoint Imaging Patient perception of "cutting-edge" Less need for commuting Practitioner travel eliminated Ability to service multiple locations Greater availability/more rapid response/more up to date Practitioners are less rushed with patients

Remote patient sensing

Disruptive technologies, including inexpensive sensors adapted to a smartphone, are increasing the ability to remotely evaluate patients. Current and imminently available capabilities include collection of standard vital signs; cardiac telemetry; visual inspection of the skin, eyes, and body cavities; and even blood and urine analysis.^83-85 Some of these technologies are proven to be effective, while others are under evaluation. With tools such as these, patients may be monitored remotely similarly to how they would be evaluated in office, potentially by APPs. The downstream multiplier of patients under the supervision of a single physician can increase dramatically. In urology, an established patient with access to personal, smartphone-based urine testing, semen testing, or serum testing for prostate-specific antigen (PSA) or testosterone coupled with telepresence could be managed from home by a PA at the office who could likewise be supervised by an off-site urologist.

Virutal collaboration and supervision

From a scientific perspective, the less ambiguous the disease presentation and treatment algorithm are, the less supervision or consultation an APP will require, assuming a satisfactory baseline level of disease-specific training and demonstrated competency. The certainty of knowledge of disease states has grown exponentially over the last century, and the ability to capture and analyze data is rapidly improving. In addition, best practice guidelines are quickly transitioning from expert opinion to evidence based. In our current data-rich environment, there are many more certain diagnoses and clear-cut treatment algorithms. Some of these conditions previously could only be understood by the most astute diagnostician. The wisdom and experience of the doctor at the bedside has been largely replaced, for better or for worse, and will continue to be replaced by datasets and microprocessors. Although the amount of medical information has exploded beyond any one human’s ability to precisely command, computers such as IBM’s Watson are able to capture every bit of the world’s English medical literature. Watson can read and understand English quickly and conduct verbal patient interviews. Watson is currently being used for prior authorizations by WellPoint and is redefining cancer protocols at Memorial Sloan Kettering Cancer Center. Watson will soon be available online to any and all.⁷⁴

The smartest clinician in the room may no longer be human and may be everywhere at once in the cloud. With ubiquitously available precise medical information, physician-level supervision or consultation services for APPs may become less necessary. SPs may take a higher order position to oversee the process rather than providing information repetitively. The number of APPs a physician can supervise or collaborate with grows proportionate to the amount of reliable information that is ready to use and that is immediately (i.e., electronically) available to the providers.

Multiplier effects of PAs and NPs and telehealth

APPs can also increase capacity through the utilization of a shared medical appointment.⁸⁶ After an initial presentation and discussion by the urologist, a virtual room full of patients with the same diagnosis, each individually logged into the encounter, can then be educated and advised by the APP while the urologist can avoid the repetitive consultations these patients would otherwise require. This is already being successfully adopted at several major centers of care. Ultimately, urologists will be able to focus on more complex patients as well as manage large populations of urology patients by utilizing modern tools of sensing and communicating. He or she will function more like a CEO whose responsibility is to ensure that a population is provided with high-quality, rapidly available urological care. In addition, hospital consultations may be increasingly handled by APPs with telemedical supervision by urologists. Surgical volume may be consolidated at centers of excellence into which smaller hospitals feed.

Medical school and residency education

Medical school and residency training may need to direct urologists into the supervisory/surgical role they will need to play. APPs can serve a valuable function in residency training by performing many of the simpler procedures that do not require as much repetition to be learned by the urology resident. In this way, the resident can focus on more complex surgical training.⁵⁴ They can also fill in provider gaps that result from federally mandated work hour limits.⁶⁸ Furthermore, it is advantageous for both urologists and APPs to begin training in collaboration early on. There will be a dramatic decrease in the total number of physicians, both primary care and specialists, that will be required for the same population, and there will likely be a generation of physicians who are caught in between the manpower shortage bubble and the brave new world of telehealth, sensor technology, and APPs. The biggest challenge will lie in how we revamp our training for all members of the health care team a generation ahead of their arrival to the marketplace. Training programs should formally incorporate telemedical technology into the curriculum to familiarize doctors and APPs with aspects of patient evaluation and collaboration that are unique to telemedicine.

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Hooker, R. S., Cipher, D. J., Sekscenski, E.: Patient Satisfaction with Physician Assistant, Nurse Practitioner, and Physician Care: A National Survey of Medicare Beneficiaries. Journal of Clinical Outcomes Management, 12: 88, 2005
Resnick, A. S., Todd, B. A., Mullen, J. L. et al.: How do surgical residents and non-physician practitioners play together in the sandbox? Current Surgery, 63: 155, 2006
Larkin, G. L., Hooker, R. S.: Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis? The American journal of bioethics: AJOB, 10: 1, 2010
Hooker, R. S., Potts, R., Ray, W.: Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. The Permanente Journal, 1: 38, 1997
Lohr, R. H., West, C. P., Beliveau, M. et al.: Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners. Mayo Clinic Proceedings, 88: 1266, 2013
Fang, M., Linson, E., Suneja, M. et al.: Impact of adding additional providers to resident workload and the resident experience on a medical consultation rotation. BMC Medical Education, 17: 44, 2017
Moote, M., Krsek, C., Kleinpell, R. et al.: Physician assistant and nurse practitioner utilization in academic medical centers. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, 26: 452, 2011
Newhouse, R. P., Stanik-Hutt, J., White, K. M. et al.: Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economic$, 29: 230, 2011
Aaron, E. M., Andrews, C. S.: Integration of advanced practice providers into the Israeli healthcare system. Israel Journal of Health Policy Research, 5: 7, 2016
Langston, J. P., Duszak, R., Orcutt, V. L. et al.: The Expanding Role of Advanced Practice Providers in Urologic Procedural Care. Urology, 106: 70, 2017
Swanton, A. R., Alzubaidi, A. N., Han, Y. et al.: Trends in Operating Room Assistance for Major Urologic Surgical Procedures: An Increasing Role for Advanced Practice Providers. Urology, 106: 76, 2017
Robles, L., Slogoff, M., Ladwig-Scott, E. et al.: The addition of a nurse practitioner to an inpatient surgical team results in improved use of resources. Surgery, 150: 711, 2011
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Gottenborg, E., Limes, J., Olson, A. et al.: Learning Together: Integration of Advanced Practice Providers into a General Medicine Ward Team. Journal of General Internal Medicine, 34: 769, 2019
American Urological Association: The State of the Urology Workforce and Practice in the United States 2018. Linthicum, MD: American Urological Association, p. 84, 2019
Canon, S., Basham, K., Canon, H. L. et al.: Alternative approaches to expanding pediatric urology services and productivity. The Journal of Urology, 188: 1639, 2012
American Association of Nurse Practitioners: Nurse Practitioner Cost Effectiveness. American Association of Nurse Practitioners, 2013
Doran, T. J., Quella, A., Coombs, J. M.: Urology procedures by PAs and NPs. JAAPA : official journal of the American Academy of Physician Assistants, 2015
Erickson, B. A., Han, Y., Meeks, W. et al.: Increasing Use of Advanced Practice Providers for Urological Office Procedural Care in the United States. Urology Practice, 4: 169, 2017
Schultz, H.: Practical and legal implications of nurse practitioners and physician assistants in cystoscopy. Urologic Nursing, 31: 355, 2011
Kadi, N., Menezes, P.: ABC of flexible cystoscopy for junior trainee and general practitioner. International Journal of General Medicine, 4: 593, 2011
Mitchell, K. A., Spitz, A.: Use of Advanced Practice Providers as Part of the Urologic Healthcare Team. Current Urology Reports, 16: 62, 2015
Smith, C. D., Balatbat, C., Corbridge, S. et al.: Implementing Optimal Team-Based Care to Reduce Clinician Burnout. NAM Perspectives, 2018
Gee, W. F.: Debate on use of advanced practice nurses and physician assistants in urology centers on procedures. Urology Times, 2012
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Hooker, R. S., Brock, D. M., Cook, M. L.: Characteristics of nurse practitioners and physician assistants in the United States. Journal of the American Association of Nurse Practitioners, 28: 39, 2016
Auerbach, D. I., Staiger, D. O., Buerhaus, P. I.: Growing Ranks of Advanced Practice Clinicians - Implications for the Physician Workforce. The New England Journal of Medicine, 378: 2358, 2018
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Hooker, R. S., Muchow, A. N.: The 2013 census of licensed physician assistants. JAAPA: official journal of the American Academy of Physician Assistants, 27: 35, 2014
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Hooker, R. S., Nicholson, J. G., Le, T.: Does the Employment of Physician Assistants and Nurse Practitioners Increase Liability? Journal of Medical Regulation, 95: 6, 2009
Miller, K. P.: Malpractice: nurse practitioners and claims reported to the National Practitioner Data Bank. The Journal for Nurse Practitioners, 7: 761, 2011
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Sherwood, B. G., Han, Y., Nepple, K. G. et al.: Evaluating the Effectiveness, Efficiency and Safety of Telemedicine for Urological Care in the Male Prisoner Population. Urology Practice, 5: 44, 2018
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Dowling, R. A., Baum, N. H.: Telemedicine: Closing the gap in long-distance care for urologists. Urology Times, 2010
Reynolds, E. M., Grujovski, A., Wright, T. et al.: Utilization of robotic "remote presence" technology within North American intensive care units. Telemedicine Journal and E-Health: The Official Journal of the American Telemedicine Association, 18: 507, 2012
McNelis, J., Schwall, G. J., Collins, J. F.: Robotic remote presence technology in the surgical intensive care unit. Journal of Trauma and Acute Care Surgery, 72: 527, 2012
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Gettman, M., Rhee, E., Spitz, A.: Telemedicine in Urology. American Urological Association, 2016
Mendez, I., Song, M., Chiasson, P. et al.: Point-of-Care Programming for Neuromodulation: A Feasibility Study Using Remote Presence. Neurosurgery, 72: 99, 2013
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Hanno, P. M.: Group visits for urology deliver efficiency, patient satisfaction. Urology Times, 2011

Appendix: Patient scenarios

The following patient scenarios are examples of a physician-led, team-based approach to patient care with APPs. In each of these scenarios, a physician may or may not be present on the initial or subsequent patient evaluation, and documentation, billing, and oversight rules and regulations may differ based on local and state regulations, insurance carriers, and setting. These scenarios are merely examples and are in no way a comprehensive list of all approaches. Furthermore, the scenarios are not intended to show favor for a particular level, method, or billing. For the purposes of these scenarios, the use of the term “APP” indicates that the listed applications apply to both PAs and NPs.

An APP may see a patient alone or share the visit with the SP. Because a PA is an extension of the physician, the physician needs to be either in the office suite or available by a reliable electronic means. NPs may not need physician oversight if seeing a patient within their state scope of practice. If an APP sees the patient alone, billing can be submitted either using the APP’s NPI number (new patients or change in plan) at 85% of the physician’s rate or “incident-to” the physician (billed under the SP’s NPI number at 100% reimbursement). “Incident-to” criteria for Medicare patients are met when a PA or employed NP sees an established patient with an established plan of care, when the PA or NP is maintaining that plan of care, and when an SP is in the office suite. The physician does not have to see or examine the patient, and the case does not need to be discussed with the physician. With proper documentation, the patient will be billed under the physician’s NPI number at 100% reimbursement. In the eyes of an insurer, every physician within one group is considered the same provider, so the SP does not need to be the same physician who made the plan. Furthermore, the billing should be submitted under the SP’s NPI number who is present in the suite, even if different from the physician who established the plan of care. In a shared visit, both the APP and the physician should document their individual involvement, and billing should be submitted using the physician’s NPI number. Local, state, and insurance carrier rules may differ slightly and should be understood and followed. For a nonemployed NP, the incident-to rules do not apply, and all bills should be submitted under the NP’s NPI number. Commercial insurance rules may differ and should be followed, as should state regulations, both of which may differ slightly.

Scenario 1: Patient with recurrent urinary tract infections (UTIs)

A healthy 66-year-old woman was referred to the urology practice of Dr. Smith and Dr. Jones for recurrent UTIs. She is seen initially by Dr. Smith, who examines her and creates a plan, including self-start therapy at the onset of symptoms. She is requested to follow-up in six months with the practice’s PA or employed NP.

Billing: New patient, outpatient visit under Dr. Smith’s NPI number (100% reimbursement)

Note: In some practices, patients such as this are initially scheduled with the APP and billing can be done either by the APP alone or as a shared visit. A shared visit occurs when the physician and the APP both see the patient, but the APP must document his or her involvement in the visit. Some practices have the APP perform the initial history, physical exam, and urine analysis and then present a plan to the physician. The physician can then see the patient, help create the plan, and document his or her involvement in the shared chart. Some practices then have the APP prescribe an appropriate antibiotic, follow-up on urine culture results, and communicate results with the patient. In other practices, the APP practices more independently.

Six months later, the patient returns to the office and is seen and examined by the APP. The patient has had one UTI in the interim. She is otherwise doing well. The APP recommends continuing the same plan of care and recommends follow-up in six months. Dr. Smith is not in the office that day, but Dr. Jones (Dr. Smith’s partner) is in the office. The APP documents that the patient is being seen “incident-to” Dr. Jones.

Billing: Established patient outpatient visit under Dr. Jones’ NPI number (100% reimbursement)

Three months later, the patient calls to be seen emergently due to fever, chills, and back pain. The office staff puts the patient onto the APP’s schedule for that day, as Dr. Smith is in the operating room but is immediately available to discuss the case by phone. Dr. Jones is out of town. The APP sees and examines the patient and recommends that she be started immediately on antimicrobial therapy and that she gets lab work and a CT scan that day. The APP instructs the patient to go to the ED if there is no immediate improvement or if the situation worsens due to the consideration of pyelonephritis. The APP calls and discusses the case with Dr. Smith, who agrees with the plan.

Billing: Established outpatient visit using the APP’s NPI number (85% reimbursement)

Scenario 2: Kidney stone

A 47-year-old male presents on a Saturday morning to the local ED with left flank pain and nausea. A kidney stone protocol CT shows a 6-mm left proximal ureter stone with hydronephrosis. The patient is afebrile, and urine analysis showed blood but no bacteria or other signs of infection. A urine culture is sent. The pain is controlled in the ED, and the patient is started on medical expulsive therapy (MET) with an alpha-blocker and provided with an analgesic and stone strainer. A referral is faxed to the urologist’s office, and the patient is discharged.

The next Monday, the office manager reviews the new referrals and schedules the patient for the APP’s clinic for the following day. The APP then sees the patient as a new patient. The patient reports that the pain has resolved, although no stone was collected. The APP performs a complete history and physical exam, calls for the old records, notes that the urine culture showed no infection, and schedules a low-dose CT scan. The patient is instructed to contact the APP for the result and to follow-up in one to two weeks. The SP is available by a reliable electronic means and is not in the office.

Billing: New patient outpatient visit using the APP’s NPI number (85% reimbursement)

Note: If the MD is in the office and examines the patient, helps create a plan of care, and documents their involvement, the visit can be billed under the MD’s NPI number at 100% reimbursement.

The CT showed that the stone remained within the proximal ureter. The APP then contacts their supervising urologist, who reviews the imaging and together they decide that it would be an appropriate time to consider intervention. At the follow-up appointment, the APP reviews the CT findings with the patient and discusses the options and the potential advantages and disadvantages of further observation with MET, ureteroscopy with lithotripsy, and shock wave therapy. The patient chooses ureteroscopy.

Billing: Established patient outpatient visit under the APP’s NPI number (85% reimbursement)

The following week, the patient presents for ureteroscopy. The urologist meets with the patient and family in the preoperative holding area to review the procedure and finalize consent. The patient then undergoes ureteroscopy with lithotripsy and stent placement.

Billing: CPT code(s) by the urologist (the pre- and post-operative work performed on that day falls within the global period of the procedure)

A week after the procedure, the patient returns to the office and the stent is removed with the attached string by the APP. The patient is instructed to complete a renal ultrasound a month after stone removal and to do a 24-hour urine collection and lab work to evaluate for a metabolic etiology for stone disease. The patient is scheduled for a follow-up with the APP in six weeks.

Billing: Established patient visit under the APP’s NPI number (85% reimbursement)

Note: If the stent was removed by cystoscopy by the urologist, CPT code 52310 (0 day global) would be billed.

Six weeks later, the APP meets with the patient, informs him that the stone consisted of calcium oxalate dihydrate, that the renal ultrasound was normal, and that the 24-hour urine collection showed a suboptimal urine volume. The APP counsels the patient regarding these findings and advises the patient (with an instructional sheet) that improved hydration and other dietary modifications could reduce the risk of future stone disease. The patient is then discharged from urology clinic with further follow-up as needed if symptoms recur.

Billing: Established patient visit under the APP’s NPI number (85% reimbursement)

Scenario 3: Erectile dysfunction management

A 55-year-old male is referred from the endocrinologist for erectile dysfunction. The patient has type 2 diabetes diagnosed five years earlier and reports developing erection problems for approximately two years prior to his diagnosis of diabetes. He reports having had sufficient trials of three different PDE-5 inhibitors, which were mildly effective initially, but no longer. He notes no decreased energy or libido, but he has had difficulty maintaining his erections. Additionally, there has been poor glycemic control (HbA1c of 9 when normal is ≤7) despite treatment with metformin, and the primary provider states that the patient has had poor dietary management. His history is also significant for hyperlipidemia managed with a statin. His labs show a total testosterone of 400 ng/dL (normal: >300 ng/dL), free testosterone of 18 ng/dL (normal: 9-30 ng/dL), and a PSA of 2.8 ng/mL.

The patient is initially seen and examined by the APP. The APP briefly discusses the case with the on-site urology clinic attending and proceeds with the treatment plan that the APP has developed. The physician enters the room, examines the patient, helps create a step-wise plan with the patient and the APP, and documents the involvement on the chart. The patient is then counseled on the different options for the treatment of erectile dysfunction (intracavernosal injections, intraurethral suppositories, vacuum erection device, etc.). The patient is also educated by the APP on the relationship between poor glycemic control and erectile dysfunction and the resulting poor response to PDE5 inhibitor for erectile dysfunction. The patient acknowledges understanding that poor erectile function is reflective of overall vascular health and is an early indicator of the development of more severe vascular disease. The patient elects to utilize intracavernosal injections. Injection training is provided, and the patient undergoes an injection trial of alprostadil in the office. He has a satisfactory response in the office and is discharged from the clinic with a prescription for 20 mcg per injection of branded alprostadil covered by his insurance and is instructed to follow up in four months.

Billing: Office consultation under the physician’s NPI number (100% reimbursement) and CPT code 54235 (injection corpora with pharmacologic agent)

At the four-month follow-up, the patient returns to the clinic to see the APP and notes that the injections allowed him to achieve but not maintain an erection. His prescription was reissued by the APP for 40 mcg with precise instructions to gradually titrate the dose upward and to check for response. It was also recommended that the patient undergo a penile Doppler ultrasound to evaluate the vascular and mechanical function of his erection.

Billing: Established patient visit under the APP’s NPI number (85% reimbursement)

The patient returns the following week and undergoes a penile Doppler ultrasound performed by the APP and interpreted by the urology attending. Results indicate that the patient has severe venous leak, and this information is conveyed to the patient. Treatment options, including placing a penile prosthesis, are discussed with the patient. After confirming the patient’s manual dexterity, the APP enlists one of the clinic RNs to demonstrate the model prosthesis device with the patient. The patient remains undecided and is instructed to review the information regarding penile prosthesis and to call if he wishes to proceed.

Billing: Established patient visit, billed under the APP’s NPI number (85% reimbursement) with CPT code 93980 (penile Doppler complete procedure [Doppler]) billed by the MD.

Note: If the physician visited with the patient to discuss the prosthesis and risks and documented their involvement, the billing would be under the physician’s NPI number. Billing for the ultrasound is based on interpretation, thus this is billed by the MD, though the procedure was performed by the APP.

The next week, the patient contacts the APP and indicates that he would like to proceed with the penile prosthesis. The patient is referred to a urologist within the group who specializes in penile prosthesis placement. The patient is subsequently scheduled and undergoes an uneventful prosthesis placement. The APP assists the surgeon on the case.

Billing: CPT code for the prosthesis billed by the MD. The AS modifier is used to reimburse for the APP’s participation with the case. There is documentation that is required in order to use this modifier. One of the following is required in the medical record:

A statement that no qualified resident was available to perform the service, or
A statement indicating that exceptional medical circumstances exist, or
A statement indicating the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients.

Ref: https://www.aapc.com/blog/23393-assistant-at-surgery/ (accessed August 6, 2020).

The surgeon sees the patient for a two-week post-operative follow-up visit; this visit falls within the global period. The patient then returns three to five weeks later to see the APP for a final wound healing check and initial device activation. The APP teaches the patient inflation and deflation techniques for the device and requests follow-up in three months.

Billing: Post-operative visit (within the global period)

The patient is again seen by the APP three months later to ensure that the patient is satisfied with the prosthesis and that there are no other issues. The patient is doing well and is instructed to contact the MD or APP if any problems arise.

Billing: Established patient visit billed under the APP’s NPI number (85% reimbursement)

White Paper Infographic [pdf]

Introduction and Purpose

Definitions

Defining the NP role

Table 1. Descriptions of non-NP/APRN roles
Certified Registered Nurse Anesthetist (CRNA): An APRN who provides the full spectrum of anesthesia and anesthesia-related care for individuals across the lifespan and through all levels of acuity. This care can be administered in diverse settings, including hospital operating rooms and pain management services. Some CRNAs specialize in particular settings or populations, such as pediatrics.
Certified Nurse Midwife (CNM): An APRN who provides the full range of women's primary reproductive health services focusing on gynecologic care, family planning services, childbirth, and newborn care. This role can include treating male partners for sexually transmitted infections. Their practice settings can be diverse and include homes, birthing centers, and hospitals.
Clinical nurse specialist (CNS): An APRN who integrates care, focusing on the interactions of patients, nurses, and systems. A continuous focus of this role is improvement of patient outcomes and nursing care with the goal of developing evidence-based practice to improve overall patient care within a system. Specific roles can include diagnosis and treatment of health and illness, health promotion, and risk factor prevention among families, groups, or communities.

Defining the PA role

NP and PA training

Supervisory/collaborative model

The role of the PA in the delivery of care should be defined through mutually agreed upon guidelines that are developed by the physician and the PA and based on the physician’s style of delegating.
The physician must be available for consultation with the PA at all times either in person or though telecommunication systems or other means.
The physician is responsible for clarifying and familiarizing the PA with his or her supervising methods and style of delegating patient care.

Core competencies

Table 2. Comparison of core competencies guiding NP and PA education programs and Accreditation Council for Graduate Medical Education (ACGME)/American Board of Urology (ABU) competencies
Milestone Concepts	Resident Competency Adpated from "urology Milestone Project" Document	Nurse Practitioner Competency Adpated from National Organization of Nurse Practitioner Faculties (NONPF) core competencies, 2011 (updated in 2012) 9 categories of compitencies	Physician Assistant Competency: Adapted from American Academy of Physician Assistants (AAPA)/Physician Assistant Education Association (PAEA) core competencies (revised in 2012) 6 categories of competencies
Foundation in urologic/medical and scientific knowledge	Patient care, practice-based learning and improvement, medical knowledge	Scientific foundation	Medical knowledge, patient care
Leadership	Practice-based learning and improvement, interpersonal and communication skills, professionalism	Leadership	Professionalism, interpersonal and communication skills
Evidence-based practice	Practice-based learning and improvement	Quality, scientific foundation	Patient care, practice-based learning
Quality improvement and research	Practice-based learning and improvement	Practice inquiry	Systems-based practice, practice-based learning
Use of technology in patient care	Systems-based practice	Technology and information literacy	Systems-based practice
Health care policy, regulation	Systems-based practice	Policy	Professionalism, systems-based practice
Organizational practice/resource allocation	Systems-based practice, professionalism, interpersonal and communication skills	Health delivery system, quality, ethics, health delivery system	Interpersonal and communication skills, systems-based practice, professionalism
Role as part of health care delivery team	Systems-based practice, practice-based learning and improvement, professionalism, interpersonal and communication skills	Independent practice, health care delivery system	Systems-based practice, professionalism
Patient care/professional ethics	Professionalism, interpersonal and communication skills	Ethics, quality	Professionalism, patient care
Scope of practice	Professionalism	Independent practice	Medical knowledge, professionalism
Procedural competencies	Patient care	Independent practice, scientific foundation	Professionalism, medical knowledge, practice-based learning
Note: Competencies not incorporated in this chart are related to resident surgical skills/training.

The following skills have been adapted from the review by Crecelius and colleagues.¹⁶

Level 1 skills

Level 2 skills

Level 3 skills

Overactive bladder/non-surgical
Urologic oncology
Male sexual dysfunction
Surgical assistance
Stone management
Female sexual dysfunction

These modules will be available on the “Education for APN/PA/Allied Health” portion of AUAnet.org.

Federal regulations

Statutory requirements

“(i) Collaboration is a process in which a nurse practitioner works with one or more physicians to deliver health care services within the scope of the practitioner’s expertise, with medical direction and appropriate supervision as provided for in jointly developed guidelines or other mechanisms as provided by the law of the State in which the services are performed.

(ii) In the absence of State law governing collaboration, collaboration is a process in which a nurse practitioner has a relationship with one or more physicians to deliver health care services. Such collaboration is to be evidenced by nurse practitioners documenting the nurse practitioners’ scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. Nurse practitioners must document this collaborative process with physicians.

(iii) The collaborating physician does not need to be present with the nurse practitioner when the services are furnished or to make an independent evaluation of each patient who is seen by the nurse practitioner.”

Mediare (billing) regulations

They must be performed in the physician’s office. Hospital inpatient services do not qualify.
Those performing the services must be employed by the billing practice.
The physician must have personally performed the initial service for a new patient to the practice, have established a plan of care, and remain actively involved in the course of treatment. The same is true for any established patient with a new medical condition. Other practice employees may implement incidental steps in the established plan of care within the scope of practice limits in their state.
While “incident to” services are taking place, a physician must be physically present in the same office suite and be immediately available to render assistance if necessary. This is described by Medicare as “direct supervision.” It need not be the physician who performed the initial service, but it must be a physician-member of the group.
Medicare reimbursement is based on 100% of the physician fee schedule amount. Unless these rules are followed, such delegated services by an APP are only paid at 85% of the physician fee schedule, and those delegated to other practice employees are not reimbursed at all.
It is important to review the contracts for other third-party payors that cover your patients as well as your state’s laws to determine to what extent you can delegate services for non-Medicare patients and how much you can be reimbursed. This will help your practice make wise decisions about how and when to delegate services.

Federal legislation

National medical organizations on APP supervision

AUA

The AUA’s most recent policy position on APPs in urologic practice states:

Role of Advanced Practice Providers and Other Allied Health Professionals

The AUA endorses the participation of advanced practice providers and allied health professionals in the care of genitourinary disease through a formally defined, supervisory role with a urologist certified by the ABU, AOBS or other certifying board for urology, under the auspices of applicable state or national law.

The American Urological Association (AUA) and the Urology Care Foundation recognize that in some areas, allied health personnel contribute to the care of the patient with genitourinary disease and, therefore, encourages the proper utilization of APPs.

Allied health personnel should be considered as para-professionals and should work in a closely and formally defined alliance with a physician.

Where the major duties of allied health personnel (i.e., NP and PA) are those of diagnosis, treatment, or management of [patients with] urological disease or problems, the designated supervising physician should be a urologist certified by the American Board of Urology (ABU).

The AUA recognizes that the role and privileges of allied health personnel vary according to individual state regulations and that the restrictions and/or controls established in any state should be honored.”

AMA

AANP

The policy environment and implications for the future

State regulations

Several resources practices might find helpful to identify state requirements:

American Academy of Physician Assistants (login information required)
American Association of Nurse Practitioners (login information required)
American Medical Association (login information required)
American Medical Association: Physician assistant scope of practice (by state)
Barton and Associates NP Scope of Practice Laws
Barton and Associates PA Scope of Practice Laws

Coding for APPs

Pateint perceptions of APPs

Kaiser Permanente Study

How COURTEOUS and RESPECTFUL was the clinician?
How well did the clinician UNDERSTAND your problem?
How well did the clinician EXPLAIN to you what he or she was doing and why?
Did the clinician USE WORDS that were easy for you to understand?
How well did the clinician LISTEN to your concerns and questions?
Did the clinician spend ENOUGH TIME with you?
How much CONFIDENCE do you have in the clinician's ability or competence?
OVERALL, how satisfied are you with the service that you received from the clinician?

Integration of APPs into practice

Although APPs can help to offset the workforce shortage facing urologists, the potential for disruption of the educational ecosystem for urology residencies must be considered at academic centers.

Academic practices

Community Practices

APPs in urologic practice

APPs performing procedures

Office procedures

There is mounting evidence regarding the increasing role of the APP in performing urologic procedures despite the lack of existing formal training, guidelines, or curriculum.

Figure 1. Independent performance of clinic procedures by APPs

Figure 2. Percentage of urologic clinic procedures performed by APPs by year

Compensation for APPs

Overall, nearly 40 percent of APP members of the AUA made more than $115,000 in 2018, higher in PAs (49.4 percent) and lower in NPs (32.8 percent).⁹

Compensation models

Straight salary is the most common compensation model for APP member of the AUA (53.0 % in PAs and 43.1 % in NPs).⁹

Urology practices are challenged with developing compensation models that are attractive to prospective APPs, acknowledging the significant impact on recruitment/retention of APPs.

A vast majority of AUA APP members reported their practices track their productivity, 91.7 percent for NPs and 83.8 percent for PAs.⁹

Annual base salary: paid to perform a particular role based on job description
Annual base salary plus productivity bonus: salary guaranteed, plus additional compensation based on a predetermined formula calculating an agreed upon amount of a set threshold of billed charges or net receipts
Percentage of net receipts: compensated based on amount billed minus accounts receivable minus overhead
Hourly rate: compensated solely for hours worked

Calculate income based on APP anticipated billing
Subtract 10% for unpaid bills
Subtract practice expenses (can be 20% to 50% of earnings)
Subtract any required physician consultation fees mandated by state licensing laws (possibly 10% to 20% of earnings; not all states require this and it varies nationally and is negotiated among providers)
Subtract a percentage for employer profit (can be up to 15% to 20% for private practice)

Additional factors considered in an APP compensation package may include the following, with the understanding that many will be influenced by practice, regional, or community standards:

Benefits offered to physicians/surgeons
Signing bonus
Compensation/allowance for CME (including allowance for airfare, room, and food for at least one national conference)
Continuing education time as a paid benefit vs. need to use vacation time
Retirement plan
Health plan/vision plan/dental plan
Compnay provided cell phone and/or pager
Car allowance
Vacation time (at least 3 to 4 weeks)
Sick time/personal days (usually 1 to 2 days/month)
Disability insurance
Employer-covered malpractice
Empolyer-covered cost for Drug Enforcement Agency (DEA) license
Payment for professional certification/license
Compensation strategy for on-call time (when applicable)
Compensation for hospital utilization (inpatientround/consults)

APPs in the outpatient setting

A vast majority of NPs see office patients as part of their clinical responsibilities.

Compared to NPs, PA AUA members are more likely to do post-operation evaluation, do procedures in the outpatient setting and perform pre-operation evaluation while also seeing patients in office.

AUA census information also reported 34.1 % of PAs and 28.3% of NPs work in four or more office locations. On average, about two-thirds of APPs work in more than one location.⁹

APPs in the inpatient setting

Malpractice and the APP in urologic practice

Liability statistics

Strategies to reduce risk

PAs: specific considerations

Satisfactory supervision of a PA from a legal standpoint may be satisfied by different configurations. (Note: the following are specific to California; check your state’s requirement.)

The patient is examined by the SP on the same day that care is provided by the PA.
The SP countersigns and dates all medical records writen by the PA within 30 days of the care provided by the PA.
Most commonly, protocols govern the diagnosis and management of patients and must include the presence or absence of symptoms, signs, and other data necessary to establish a diagnosis or assessment. Protocols also specify any appropriate tests or studies to order. Medication recommendations and patient education are included. Details of informed consent for procedures as well as preparation for and technique of any procedure that is to be performed are included. Follow-up care is also included in protocols. These protocols do not necessarily have to be written out and may reference texts if those texts are readily available to the PA (including on the internet). When protocol supervision is employed, the SP must sign 5% of charts within 30 days of care.⁷²

NPs: specific considerations

Disruptive technology and APPs

Figure 3. Annual rates of surgeon and APP assistance by procedure category

Robotic remote presence technology

Currently deployed systems are configured as follows:

Bidirectional video on mobile cart
Secured VPN broadband connection
Recording/archiving capability
Split/multiple screens for multiple types of information
Well-informed practitioner attending to patient
Additional sensors providing data
Stethoscope, ultrasound, infrared, telemetry

Various telemedicine programs now exist in every state. Although the technology was initially aimed towards remote outreach, it offers several advantages for local care (Table 3).

Table 3. Advantages of telemedicine
Telemedicine involves multimodality communication between providers and patients as well as between providers to increase the transfer of knowledge. Advantages include the following: Telestration Texting/text chat PowerPoint Imaging Patient perception of "cutting-edge" Less need for commuting Practitioner travel eliminated Ability to service multiple locations Greater availability/more rapid response/more up to date Practitioners are less rushed with patients

Remote patient sensing

Virutal collaboration and supervision

Multiplier effects of PAs and NPs and telehealth

Medical school and residency education

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Appendix: Patient scenarios

Scenario 1: Patient with recurrent urinary tract infections (UTIs)

Billing: New patient, outpatient visit under Dr. Smith’s NPI number (100% reimbursement)

Billing: Established patient outpatient visit under Dr. Jones’ NPI number (100% reimbursement)

Billing: Established outpatient visit using the APP’s NPI number (85% reimbursement)

Scenario 2: Kidney stone

Billing: New patient outpatient visit using the APP’s NPI number (85% reimbursement)

Note: If the MD is in the office and examines the patient, helps create a plan of care, and documents their involvement, the visit can be billed under the MD’s NPI number at 100% reimbursement.

Billing: Established patient outpatient visit under the APP’s NPI number (85% reimbursement)

Billing: CPT code(s) by the urologist (the pre- and post-operative work performed on that day falls within the global period of the procedure)

Billing: Established patient visit under the APP’s NPI number (85% reimbursement)

Note: If the stent was removed by cystoscopy by the urologist, CPT code 52310 (0 day global) would be billed.

Billing: Established patient visit under the APP’s NPI number (85% reimbursement)

Scenario 3: Erectile dysfunction management

Billing: Office consultation under the physician’s NPI number (100% reimbursement) and CPT code 54235 (injection corpora with pharmacologic agent)

Billing: Established patient visit under the APP’s NPI number (85% reimbursement)

Billing: Established patient visit, billed under the APP’s NPI number (85% reimbursement) with CPT code 93980 (penile Doppler complete procedure [Doppler]) billed by the MD.

Billing: CPT code for the prosthesis billed by the MD. The AS modifier is used to reimburse for the APP’s participation with the case. There is documentation that is required in order to use this modifier. One of the following is required in the medical record:

A statement that no qualified resident was available to perform the service, or
A statement indicating that exceptional medical circumstances exist, or
A statement indicating the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients.

Ref: https://www.aapc.com/blog/23393-assistant-at-surgery/ (accessed August 6, 2020).