Dear List Subscribers:

Our pediatric emergency department is situated in a large teaching
hospital, and sees a significant number of children aged 18-21.  For
institutional reasons, we are seeing a great deal more recently.

Our group is just curious to know- what upper age limit applies for
your PED?

Do different rules apply to different settings?

What should the upper age limit be?


Geoff Capraro
PEM Fellow Boston Medical Center

------------------ Reply Separator --------------------
Originally From: Richard B Ismach <[log in to unmask]>
Subject:  Re: NP's in ED
Date: 09/08/2001 03:00pm

Kate, et al -

As I told you off-line, we use both Nurse Practitioners and
Physician Assistants in our adult ED fast track.  We use NPs and PAs
interchangeably, but in a few ways PAs are better:

   * In Georgia, PAs can prescribe independently, but NPs cannot
     (not a problem in most states).
   * PAs usually have better procedural training (e.g., wound
     repair) at graduation.  After a few years of practice, the
     difference vanishes.
   * PAs are trained to practice fairly independently, but to work
     with and under a physician's direction.  Some NPs expect to
     practice completely independently, without any interference
     from a physician.  In an ED setting, a physician will certainly
     be named in any lawsuit involving a non-physician provider.
     Thus, EPs are sometimes more comfortable working with PAs than
     with NPs.

Despite these issues, we are happy with a mix of PAs and NPs in our
fast track.

Billing is as Zach outlined: both NPs and PAs can bill (at 85% of
the physician's fee) for E&M or procedural services.  However, many
private insurers, at least in Georgia, are now refusing to pay for
PA or NP services in the ED.  It is well established that customers
(patients) are better satisfied and costs are lower with
non-physician providers.  Thus, this seems to be just a ploy to
avoid paying some claims.  Still, this may be a major issue in some

The alternative is for the physician to bill for services of the PA
or NP.  I am less familiar with this - all the departments I've
worked in had the non-physician provider bill directly, using their
own number.  This requires the physician to see each patient, a
potential problem for everyone's efficiency.

Some PA resources on the web:


Richard B Ismach, MD, MPH
Assistant Professor of Emergency Medicine
Emory University School of Medicine
Office: (404) 712-9656
Pager:  (404) 686-5500 -> 11037

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