Although the PA may spend extra time explaining a planned procedure to the patient, the orthopaedic surgeon should make the first postoperative visit to the patient.


Published 3/1/2008
Charles E. Rhoades, MD

How to use physician extenders

Four ways to integrate PAs into your practice

Integrating a physician extender into your office isn’t a matter of “one-size-fits-all.” How you use a physician assistant (PA) depends on many factors, but PAs may be integrated into orthopaedic offices primarily in the following four ways:

  • Operating room (OR) assistant only
  • Independent practice without a physician present
  • Independent practice with a physician in attendance
  • Practicing “incident to” an attending physician

Operating room assistant only
Using a physician extender only in the OR can increase turnover efficiency, provide greater continuity of care from case preparation, and free up the primary surgeon’s time at the beginning and end of each case.

Medicare and many commercial insurance companies provide reimbursement (approximately 15 percent of the basic surgical fees) for the services of a skilled surgical first assistant on certain cases. A list of cases that are deemed appropriate for a skilled surgical first assistant is available from the Centers for Medicare and Medicaid Services (CMS) and can be found on the CMS Web site (

Some physician extenders may find this role professionally satisfying. Many others, however, may desire to use their education not only as a first assistant, but in the diagnostic and treatment phases of patient care in the orthopaedic office.

Independent practice without a physician present

Many states allow physician extenders to have an independent clinical practice without a physician present. States have specific rules and regulations regarding how far away the supervising physician can be, how much time can elapse before the supervising physician responds to an emergency, and what the physician extender can do in the specific situation.

Independent practice with a physician in attendance
Many offices use this model, in which the physician extender sees patients and has an office within the practice’s offices, where an attending physician is present. The PA may have his or her own clinic and patients and is able to develop long-term patient relationships in the orthopaedic office.

Billing for the PA’s services, using the PA’s national provider identification (NPI) number is at approximately 80 percent of the physician’s rate. Under this model, the PA might see walk-in patients, handle uncomplicated fracture work, provide emergency department follow-up, conduct low back pain and heel pain screenings, and treat other common orthopaedic problems.

“Incident to” an attending physician
Physician extenders may bill under the physician’s NPI if they are practicing in the same office at the same time under the “incident to” rules. Specific Medicare regulations apply to physician hands-on visits for new problems, first-time Medicare visits, and follow-ups after a certain number of visits. This category of service is billed under the physician’s name and at the physician’s rates.

If the PA is practicing in this environment, one of the following methods may be used to see patients: parallel clinic with the attending’s patients, “leap-frog” method, and joint visits.

In a parallel clinic situation, the PA works independently in a room(s) next to the attending physician and sees the attending physician’s private patients.

The leap-frog method has the physician and the PA working through the clinic and alternating seeing patients as they arrive. The physician may spend a short time with patients being seen by the PA.

Finally, the physician and the physician extender may work together in the same room 100 percent of the time, jointly visiting each patient. Although convenient for the orthopaedic surgeon, this arrangement is probably the least efficient method. From a professional viewpoint, it is also the least satisfying to the PA, because it limits his or her ability to make independent judgments, formulate treatment plans, and exercise professional education.

Charles E. Rhoades, MD, is a member of the AAOS Practice Management Committee. He can be reached at

Avoiding problems
Physician extenders should be used to enhance patient care. The physician assistant (PA) should not be a substitute for the physician, but a professional extension of the physician’s expertise. To avoid misunderstandings or problems, heed the following pointers:

  • Tell patients in advance that they will be seeing a PA. Assure them that the orthopaedic surgeon is nearby and ready to respond if needed.
  • If the patient seems uneasy about seeing a PA, be very amiable and accommodate any request to see the orthopaedic surgeon. The surgeon can then transition future visits to the PA if needed.
  • The orthopaedic surgeon—not the PA—should see and follow up with any patients who have complications.
  • The orthopaedic surgeon—not the PA—should make the first postoperative visit to the patient. No one can explain the surgery better than the person who performed it.
  • The physician should support and back the PA in front of the patient. Statements such as “that is not what I would have done” are damaging and counterproductive.