I'm not a physician, so I'm speculating here.
Radiology techs, phlebotomists, PSG techs, etc do not have the ability to independently bill CMS. They do have CPT codes for performing the blood draws, making people sit still in the MRI, etc. These "get the sample" CPT codes are distinct from the physician's "interpret" CPT codes.
I'm guessing the tech CPT codes are billed as "incident to" or "technical component" or something similar (e.g., physicians who sign lab orders for "get your own labs" companies).
My point is that medicine already has a model to reimburse physicians for "We will pay you for your signature, because it is necessary for other people to work". I am perplexed as to why it's not the same for nurse practitioners.
Not that it really affects me. Just curious.
The phlebotomist is not generally employed or even working with a pathologist unless the pathologist owns or is medical director of the lab. Here are some examples of how pathologists and radiologists are using techs and PAs.
1. Path techs cut up sections that have been initially processed by either the pathologist or the PA. They do all the legwork on turning a 1 cm cut into 100 slides for a microscope. Then they sort through these slides to see which ones are the highest quality or most representative. They then select ~10 of those to be seen by the pathologist. The pathologist bills for the review of those 10 slides. Then the pathologist decides which additional stains may be necessary and the tech performs those stains. The pathologist reviews them and bills for those slides as well. Without a tech a pathologist goes from reviewing several thousand slides in a week to several hundred. Clearly the pathologist makes way more money when the tech does that prep work.
2. For simple things like pap smears to detect cervical cancer, it's a similar setup. The OB, family med, or NP obtains the sample. That sample is sent to a lab where techs turn them into smears. Techs review thousands of smears. 90% are normal. The 10% that are abnormal are reviewed by a second tech. 10-100% of those are abnormal after second review. So the pathologist reviews ~1-10% of the total sample. Of those 1-10%, 1-10% of them are determined to require further workup. They communicate a report to the provider who obtained the sample. That provider then either does another test or refers the patient for surgical removal.
The removed cervix or uterus is sent to the path lab where the steps from 1 are repeated. In this way an entire city can be monitored by 2-3 pathologists specializing in cytopath.
3. Examples where the pathologist obtains the sample: bone marrow biopsy, kidney biopsy (frequently done by other doctors but in some systems this is the case). The pathologist obtains the sample, does a quick-and-dirty mounting of a section on a slide and reviews it briefly to make sure it's a good biopsy. Then that biopsy is sent to the lab for techs to prep many more slides and review them for the pathologist to review as in 1. This is much slower, since in the time it takes to obtain the biopsy and confirm it, the pathologist could have signed off on 50-100 slides.
In general, with pathology you know that 90-99% of samples will be completely normal and on average 1% or less will indicate something clinically actionable. So a pathologist really only needs to review 1-10% of them to still be doing overkill. The system is set up so that the ancillary providers will ensure the pathologist is making the best use of their time for the society.
For all the work that the techs do, yes that is all billed as having been done. The real money comes in from the pathologist reviews. Like 1000x more.
For a diagnostic radiologist: they're paid per imaging study. Without the tech, how is the radiologist going to review a thousand images a day? It takes 5 minutes or more to obtain a chest xray but around 10 seconds to review it. The tech obtains several images and determines which image is high quality enough to warrant a review by the rafiologist. The additional billing from the obtaining of the images is very minimal. Less than $5 usually. Reviewing it is many multiples of that. Clearly the tech makes mega bucks for the radiologist solely by obtaining the image, with the money billed for obtaining the image frequently not even covering the use of the machine or the cost of the tech.
Psychiatry is completely different. You can't look at a slide for 5-10 seconds and decide something as important as clinical changes in psychiatric treatment, dictate a report in 5-20 seconds that indicates this, and have the NP implement the change. NPs can't screen 100 people who present for an evaluation and determine that only 1% of them need psychiatric treatment, the other 99% can come back in 3-10 years for another exam. That would be absurd.
