We tend to assume every medical procedure is performed by an MD or DO. That makes sense—those are the names on the diplomas. But in real clinical life, lines shift. And that’s exactly where confusion arises: when you're lying on an exam table, who’s actually doing the biopsy? Does it even matter, as long as it’s done right?
Who Is a Physician Assistant, Really?
Let’s start with what a PA actually is—because a lot of people don’t know. They’re not nurses. They’re not residents. They’re licensed clinicians trained in the medical model, not the nursing one, which means their education mirrors med school in structure. Two years of classroom work, then clinical rotations across specialties—surgery, internal medicine, pediatrics, you name it. Most complete over 2,000 hours of clinical training before ever stepping into a job. They take a national certifying exam (PANCE), and they must log 100 hours of continuing education every two years to stay certified.
But—and this is where it gets tricky—not all PAs do the same things. Some work in dermatology, doing skin biopsies all day. Others are in the ER, suturing lacerations or interpreting EKGs. Some assist in open-heart surgery. Scope varies wildly. One PA in rural Montana might be the only provider within 80 miles. Another in Boston could be part of a neurosurgery team at a Level 1 trauma center. The profession is built on adaptability, which is great—until someone asks, “Wait, can they do a biopsy?” Then you realize: there’s no single answer.
Training Paths That Lead to the Needle
Some PA programs offer procedural electives—a few extra months focusing on dermatology, for example, where skin punch biopsies and shave biopsies are routine. Others emphasize surgical skills. But not all do. Which explains why two PAs, both certified, might have vastly different levels of hands-on biopsy experience. One might have done 50 punch biopsies during rotations. The other? Zero.
Then comes onboarding. A new PA hired at a dermatology clinic will likely train under a supervising physician for weeks—sometimes months—before performing biopsies independently. Even then, “independently” is relative. Most states require physician availability within a certain radius, though they don’t need to be in the room. In Alaska, for instance, that distance can be up to 100 miles. In New Jersey? The supervising physician must be on-site. That changes everything.
Legal Boundaries: Where Biopsies Fall in State Law
This is the messy part. There is no federal rule saying, “Yes, PAs can do biopsies.” Instead, it’s dictated by 50 different state medical boards—plus Washington, D.C., and U.S. territories. And each state interprets “scope of practice” differently. In Texas, PAs can perform invasive procedures like biopsies if delegated by a physician and outlined in a formal practice agreement. In California, the law is more restrictive—biopsies may be permitted, but only if explicitly included in the supervising physician’s delegation plan.
Some states, like Washington, empower PAs through “collaborative agreements,” which allow for broader autonomy as long as there’s a formal relationship with a physician. Others, like New York, still treat PAs as extensions of the physician’s license—meaning the supervising doctor assumes liability. And that’s not just a technical detail. It shapes whether a clinic will even let a PA near a biopsy tray.
The Role of Institutional Policy
Even if state law allows it, individual hospitals or clinics can impose stricter rules. A private dermatology group might authorize all their PAs to perform biopsies—after a six-month training period. But a university hospital system could require physician-only procedures, regardless of state law. Insurance also plays a role. Reimbursement for a biopsy done by a PA is usually the same as one done by a doctor, but some payers have caveats. Medicare, for example, covers PA-performed biopsies under “incident to” billing rules—meaning the service must be part of a physician’s treatment plan.
And let’s be clear about this: just because a PA can do a biopsy doesn’t mean they will. Some decline due to comfort level. Others avoid it because of liability concerns. One study from 2022 found that only 58% of PAs in outpatient settings regularly perform biopsies—despite being legally permitted in 44 states. Experience, confidence, and institutional culture matter more than law sometimes.
Types of Biopsies PAs Actually Perform
Not all biopsies are created equal. There’s a world of difference between snipping a skin tag and doing a core needle biopsy of the liver. Most PAs who do biopsies stick to the surface—literally. Superficial skin biopsies are the most common. Think melanoma checks, rashes, or suspicious moles. These include shave biopsies, punch biopsies (using a circular blade), and excisional biopsies for small lesions.
Then there are deeper procedures. In surgical settings, PAs often assist with biopsies during operations—removing lymph nodes or tumor samples. Some, especially in specialties like gastroenterology or pulmonology, may perform or assist with endoscopic biopsies. But these are almost always under direct supervision. Needle biopsies of organs? That’s rare for PAs. You won’t find many doing a percutaneous kidney biopsy solo. The risk is too high, the margin for error too thin.
How a Skin Biopsy Actually Goes Down
Picture this: a 62-year-old man comes in with a scaly patch on his forearm. The PA examines it, suspects actinic keratosis—pre-cancerous. They discuss options: biopsy or treat empirically? The patient opts for the biopsy. The PA cleans the area, numbs it with lidocaine (that sting lasts two seconds), then uses a 4mm punch tool—like a tiny cookie cutter—to extract a sample. Pressure is applied, maybe a single suture. The tissue goes to pathology. All takes less than 10 minutes.
This is routine. Efficient. And honestly, it’s hard to argue it needs an MD when a trained PA can do it just as well. Studies show no significant difference in complication rates or diagnostic accuracy between PA- and physician-performed skin biopsies. One 2020 review in the Journal of the American Academy of PAs looked at over 3,000 cases—equivalent outcomes, same follow-up rates. So why the hesitation?
Physician Supervision: How Close Is "Close Enough"?
The problem is perception. Patients see “Dr.” on the door and assume it’s the one holding the scalpel. But increasingly, it’s not. And that’s fine—if trust is maintained. The supervising physician doesn’t need to watch every biopsy. In most states, they just need to be available. Some require a co-sign on notes. Others don’t. Telemedicine has blurred the lines further. A PA in Flagstaff could do a biopsy while the supervising dermatologist in Phoenix reviews images remotely minutes later. Is that supervision? Legally, yes. Emotionally? That depends on the patient.
Because here’s the thing: we’re far from a post-physician world. PAs aren’t replacing doctors. They’re extending their reach. In areas with physician shortages—rural Appalachia, parts of the Navajo Nation—PAs are often the only providers doing biopsies at all. Without them, patients wait months. And that’s exactly where the debate gets emotional. Is it better to have a biopsy done by a PA now—or by a dermatologist in six months?
PA vs NP vs MD: Who Actually Does Biopsies?
Let’s compare. Nurse practitioners, like PAs, can perform biopsies in many states—especially in dermatology or family practice. But their training differs. NPs come from nursing backgrounds, often with years of bedside experience before advanced training. PAs are trained as generalists first, then specialize. In practice, both can be highly skilled. But in some institutions, NPs face fewer restrictions on procedural autonomy, especially in states with full practice authority for nursing.
And MDs? Of course they do biopsies. But they’re not always the best at it. I am convinced that procedural skill has less to do with letters after a name and more to do with volume and focus. A dermatology PA who does 10 biopsies a week likely outperforms a general internist MD who does one every few months. Skill is muscle memory. That said, complex or high-risk biopsies still belong in the hands of specialists—MD or DO.
When a PA Shouldn’t Perform a Biopsy
Sure, they can—but should they? Not always. Deep tissue biopsies, those near major vessels or in delicate areas (like the orbit or spinal cord), are generally off-limits. So are cases with high bleeding risk or unclear anatomy. And if the PA isn’t trained or comfortable? Walk away. That’s not weakness. That’s good medicine. One malpractice case in Ohio involved a PA performing a deep skin excision without proper training—resulting in nerve damage. The settlement? $420,000. The supervising physician was also held liable.
Which brings me to my personal recommendation: if you’re a patient, ask. Politely. “Who will be doing the biopsy?” and “How many have you done?” are fair questions. If it’s your first time, you deserve to know. Transparency builds trust. And trust? That’s the real foundation of care.
Frequently Asked Questions
Can a PA perform a breast biopsy?
Generally, no—not independently. Breast biopsies, especially stereotactic or ultrasound-guided core biopsies, are complex. They’re typically done by radiologists or surgeons. PAs may assist in surgical breast biopsies during lumpectomies, but they don’t usually perform diagnostic needle biopsies alone. The margin for error is too high, and imaging guidance requires specialized training most PAs don’t have.
Do patients prefer doctors over PAs for biopsies?
Data is still lacking. Some patients express discomfort when told a non-physician will perform a procedure. Others don’t care—as long as it’s done well. A 2021 survey found that 72% of patients were satisfied with PA-performed skin biopsies when properly informed. But 28% said they’d have preferred a doctor. The key? Clear communication. Surprise is the enemy of trust.
Are PA-performed biopsies covered by insurance?
Yes, in most cases. Medicare, Medicaid, and private insurers reimburse for biopsies performed by PAs under appropriate billing codes (like “incident to” services). But documentation must be thorough. The supervising physician’s name, the delegation agreement, and medical necessity all matter. A poorly documented biopsy could be denied—even if the procedure itself was flawless.
The Bottom Line
Can a PA do a biopsy? Yes—but with strings attached. State law, training, supervision, and institutional policy all act as filters. In dermatology clinics, rural health centers, and surgical teams, PAs perform biopsies every day. The outcomes? Comparable to physicians. The cost? Lower. The access? Greater. Yet the hesitation persists. Maybe it’s tradition. Maybe it’s ego. Or maybe we just haven’t caught up to the reality of modern care delivery.
Suffice to say, the needle doesn’t care who holds it. What matters is skill, judgment, and the ability to know your limits. A PA with 500 biopsies under their belt is probably more competent than a newly minted doctor who’s never done one. But that doesn’t mean every PA should do every biopsy. Medicine isn’t about titles. It’s about responsibility. And sometimes, the most responsible move is knowing when not to act.