Q. Does state statute mandate that a statement about PA supervision be documented in outpatient chart notes?

PA Supervision Q. Does state statute mandate that a statement about PA supervision be documented in outpatient chart notes? A. There is not a specific requirement for this, other than a PA must be able to identify who their supervising physician is for every patient encounter. One way to satisfy this requirement is to put the supervising physician's name in each clinic note. Some PAs use a schedule or keep track based on how they log into the EMR. I assume identifying the supervising physician in the clinic note was the recommendation at the meeting, but this is not explicitly required in Chapter Med 8. Q. Supervision of PAs in the ER Do PAs need to staff every patient seen with the emergency physician? A. No. The constant physical presence of a supervising physician is often unnecessary. The supervising physician and the physician assistant are jointly responsible for employing more intensive supervision when circumstances require direct observation or hands-on assistance from the supervising physician. LEGAL OPINION: The constant physical presence of a supervising physician is often unnecessary. The supervising physician and the physician assistant are jointly responsible for employing more intensive supervision when circumstances require direct observation or hands-on assistance from the supervising physician. The suggestion that every single visit has to be staffed with the ER doc is simply contrary to this language. The only way to reconcile the positions would be if the ER director is trying to say that every single patient who walks into the ER presents with a problem that requires direct observation and/or hands on assistance from a physician but that would be an enormous and unsupportable factual stretch. My recollection from discussions at the time is that the exception embodied in the rule requiring physician presence at times was meant to be narrow (hence the often unnecessary language) and was addressing those PA/physician relationships involving more specialized practices such as cardiovascular surgery, etc. Also, if you look at the definition of supervision in Med 8.02(6) it is clearly broad enough to encompass both direct supervision and general supervision. Again, my recollection of the discussions at the time of enactment was that the language needed to be that broad but also make clear that if there was a disagreement between a physician and a PA, that the physician s decision controlled. Hence the powers of direction and decision language. I always thought that was a bit odd that anybody felt the need to make that explicit but, in fairness, it is the only place in the rule that is that explicit. Q: My supervising MD oversees myself and two other providers. He is leaving our company, taking a new job with a different company. Our regional medical director is in Chicago and suggested he be our new supervising MD however, he does NOT have a WI medical license, only IL. I ve looked on the state board of Medicine website (drl.wi.gov) and Chapter 8 references supervising MD s, but gives no indication of whether or not the supervising MD has to be licensed in our state. 1. Do we have to have an WI state licensed MD to supervise us OR can it be any licensed physician 2. Can our current supervising MD continue to be our supervising MD even if he is not at the same company anymore (which he said he would be willing to do if we needed him to). 1

A. When State of Wisconsin statutes and code refer to a license they are referring to a State of Wisconsin issued license. Any physician without a State of Wisconsin issued license cannot serve as a supervising physician to a PA practicing in Wisconsin. If the physician has a valid State of Wisconsin license (or has the exemption noted below), they can serve as the supervising physician for a PA regardless if the PA and MD are employed by the same entity. Wisconsin Administrative Code; Chapter Med 8; Med 8.07 Practice. (1) Scope and limitations. In providing medical care, the entire practice of any physician assistant shall be under the supervision of one or more licensed physicians or physicians exempt from licensure requirements pursuant to s. 448.03 (2) (b), Stats. Wisconsin Statute; Medical Practice; Statute 448.01(5). Physician means an individual possessing the degree of doctor of medicine or doctor of osteopathy or an equivalent degree as determined by the medical examining board, and holding a license granted by the medical examining board. This subsection does not apply in s. 448.980. NOTE: Sub. (5) is amended eff. 12-16-19 by 2015 Wis. Act 116 to read: (5) "Physician" means an individual possessing the degree of doctor of medicine or doctor of osteopathy or an equivalent degree as determined by the medical examining board, and holding a license granted by the medical examining board. Q. Is there a Medicare rule that states PA s and residents cannot be supervised by the same physician at the same time? A (LEGAL OPINION). I know of no restriction in this regard and frankly it doesn t seem like it would make sense. One would think resident should be being trained how to work within a team approach. There are also plenty of examples to the contrary I can think of. For instance, surgical PA s regularly assist with surgeries while resident look on. This string suggests that there may be Medicare billing exceptions in certain situations. I looked at the particular rule being cited and it is so narrow that it is effectively written in manner to show people how not to run afoul of the billing strictures. I don t see this as a big issue. Q. My supervising doctor left abruptly due to a medical emergency. I currently have no supervising doctor. Can I continue to see patients? In our rural clinic, there is just me and an NP seeing patients. A. When PAs work alongside an NP, the NP s collaborating physician would be the best choice as the supervising physician. Otherwise, a supervising physician in another location needs to be identified. Q. Are PAs in WI required to have every note co-signed by a physician? A. No. There is no co-signature requirement for PAs in Wisconsin. There is no official document that specifically indicates that PA notes do not need co-signature. We can only reference Chapter Med 8 and point out that there is no co-signature requirement therein. Furthermore, there is no co-signature requirement when billing Medicare "incident to" the physician. The requirements for billing "incident to" are: Services are provided in a physician s office or physician s clinic; Physician sees Medicare patient on initial visit, establishes a diagnosis and treatment plan. PA sees patient on follow-up visit; For established Medicare patients with a new problem, the physician sees the patient first for the new problem, establishes a diagnosis and treatment plan, PA sees patient on follow-up visit 2

A Physician is on site, within the suite of offices, when the patient is seen by the PA; Services are within the PA s state law scope of practice; and The PA represents a direct financial expense to the physician billing (W-2 or leased employee, or independent contractor). The physician must continue to see the patient at a frequency that reflects ongoing management of the patient s care. Q. Are PAs required to list all physicians they could potentially work with on the supervising physician form with the state? A. Only one supervising MD needs to be listed on the form. Q. Can the PAs name be listed as the Primary Care Provider in the Electronic Medical Record? A. Yes. Under the ACA, PAs are recognized as PCPs. If an employer claims a PA cannot be listed as a PCP in the EMR, it should be investigated whether that is due to an EMR limitation that can be addressed. Q. Are PAs required to have a monthly site visit from their supervising physician? A. No. Visits were an old requirement that was removed from Med 8 when it was last updated. Scope of Practice Q. Can PAs sign DNR Bracelets? A (LEGAL OPINION). DNR bracelets must be signed by the physician. 154.19 is very poorly written and confusing. An argument could be made for a PA to be able to sign the bracelet on the physician s orders, but it could also be read to allow the physician to delegate the simples mechanics of the process (enter the conversation in the chart, act as scrivener for the doc on the order and physically place the bracelet). What leads me to my conclusion is the phrase in 154.19(2)(b)1 a do-not-resuscitate bracelet that meets the specifications established under s. 154.27 (1). If you look at 154.27(1), one of the specifications for the bracelet is the signature of the attending physician. I think when read in the context of 154.27(1), the confusing language of 154.19, while not given any clarity, would be interpreted to require that the physician be the one signing the bracelet. Stated another way, if a situation went bad where a responder ignored a DNR bracelet because it was signed by a PA, I would think the responder s actions completely justifiable, which in turn could cause a potentially big problem for the PA. Q. Can PAs perform DOT exams? A. PAs should not perform DOT physicals unless their supervising physician or someone in their group is certified. 3

Q. Can PAs perform/submit Prior-Authorizations? A (AAPA OPINION). Yes, as long as the drug is within a PA s state law scope of practice/prescribing authority to prescribe. Q. Can PAs sign Death Certificates? A (LEGAL OPINION). No. Chapter 69 controls vital records which includes death certificates and the other paperwork necessary for transporting of corpses, reporting cause of death, notifying law enforcement of suspicious deaths etc. Perhaps not surprisingly, one bit of data that must be on all those records is the date of death and the Date of Death is specifically defined by statute as the date a person is pronounced dead by a physician, coroner, deputy coroner, medical examiner, deputy medical examiner, or hospice nurse. Q. Can PAs work with Chiropractors or acupuncturists? A. No. PAs are prohibited from practicing with Chiropractors or acupuncturists. Q. Is it within the PA s scope of service that they can independently explain the risks and benefits of undergoing a procedure, or does the physician need to always co-sign the record they create explaining the risks and benefits? A. PAs can explain the risks/benefits of a procedure if this is allowed by the facility or employer. It is a delegated service performed by the PA. This falls under scope of practice in Med 8. Q. Do PAs need special certification to read and bill for reading EKGs? A. PAs do not need any certification to read EKGs. WAPA is not aware of any billing restriction with Medicare. Q. Are PAs able to apply fluoride varnishes in Wisconsin? A (LEGAL OPINION). I m actually a little concerned on this one. (Application of fluorides and other topical agents approved by the American dental association for the prevention of oral disease is an activity specifically referenced in Administrative Code covering dentistry as a practice of dental hygiene. Wis. Admin. Code sec. DE 3.02(2)(e). There may be more specifically going on with the practices at this clinic that could walk the issue back a bit, but as the question is framed, this is not an activity the WAPA should put its blessing on. Q. Can PAs perform truck driver physicals that their supervising physician is not certified to perform? A. WAPA previously sought legal counsel on this issue, and were warned against PAs performing DOT physicals if their supervising physician or someone in their group is not certified as well. It is a grey area, but that was the official opinion of counsel. 4

Q. Can PAs dispense sample medications? A. Yes. PAs can dispense. Chapter 961 of the Uniform Controlled Substance Act, specifically includes PAs in the definition of a practitioner. Billing Q. Can PAs bill for e-visits? A (LEGAL OPINION). Prior to the MEB s telemedicine ruling, PAs were restricted if there is no physician to reach out to within the fifteen minute rule. Q. Do PAs need special certification to read and bill for reading EKGs? A. PAs do not need any certification to read EKGs. WAPA is not aware of any billing restriction with Medicare. Q. Does a PA need to indicate to the name of the supervising physician when billing for visits? A. When PAs bill for visits, the payer does not need to know the name of the supervising physician. Employment Q. Can PAs in WI be employed by service corporations? A (LEGAL OPINION). Corporate practice of medicine (CPOM) questions are kind of tricky here as there is no clear guidance. I think the most recent thing is a 30 year old Attorney General Opinion. Unlike some other states, Wisconsin does not have a single CPOM statute but the rules are cobbled out of other rules and referred to as our COPM law. Physicians can practice through a service corporation structure and some professional partnerships. I interpret the question below to be asking if a PA can have an ownership interest in any allowable structure and my guess is that doing so would run afoul of the selfemployment restriction in Med 8. Normally, CPOM is more concerned with fee sharing than this issue. Q. I'm looking at possibly applying for an independent contractor position with Horizon Health, Inc. in the Milwaukee metro area, however, Chapter Med 8 states PAs cannot be self-employed. Does this means PAs cannot work as independent contractors in the state of WI? And if so, then why would this company advertise this type of a position? A (LEGAL OPINION). While neither I nor any of my partners who specialize in labor and employment have seen an enforcement action against PA employment as a 1099 independent contractor, nor are we aware of any Department letter providing a formal or informal blessing to such arrangements, it seems to run directly counter to the provisions of Med 8.09. The law is fairly clear as to specific categories of folks who do work for a business on a regular basis. The primary categories are employees (W-2 earners), partner/owners (K-1 earners) and independent contractors (1099 earners). 1099 earners are, by definition, independent contractors for most employment and all taxable purposes. Without more information directly from the employer about the specifics of the arrangement, I have to stop short of explicitly condemning the practice, but I do think there are red flags all over this. 5

While I think Anne is right as to the purpose and intent of the law, the language of the administrative rule is very clear and a facial reading prohibits this type of arrangement. I seem to even recall a very brief discussion on this during the last Med 8 revision in which we thought that was a good idea as it provides additional employment protections to PAs. The concern was that if 1099 employment were foreclosed, it might make PA usage less attractive. Not a lot of time was spent on this as no one was aware of it being an issue and the thought was that while we want maximum employability, that should not come at the expense of what PA s would lose in employment protections. There are a lot of ancillary issues that come out of this as to what constitutes supervision and supervising physicians, how workers compensation is handled, what are the professional liability insurance provisions protecting the PAs, the arrangements that constitute agency for vicarious liability purposes etc. The manner in which these things are handled, I suppose, could be influential on the question of whether their specific arrangement runs afoul of Med 8.09 but that would be walking a tightrope with the IRS and FLSA enforcement. I have to think Horizon Health would be aware of this and has sought legal advice, but they may not have; if they have, I would love to hear their thought process. I think the member would be well advised to ask Horizon if they have addressed this issues and how they have dealt with it. The member certainly does not want to take any action that could subject them to a licensing action. In this regard, I would also note for the record that DSPS has jurisdiction over the licensed professional, but not necessarily the employer. It would be unfortunate to see a member sanctioned because a prospective employer led them into a situation that violates the regulations. Licensure Q. Does Wisconsin require ongoing NCCPA certification for licensing renewals? A. Wisconsin does require ongoing NCCPA certification. If a PA license is allowed to lapse, the PA would have to go through the entire process of application again including the tests. Refer to this section from WI Admin Code: Med 8.05(1)(cm)(cm) - Proof that the applicant is currently certified by the national commission on certification of physician assistants or its successor agency. 6