WAPA is working hard to ensure physician assistants (PAs) are well-positioned to fill the needs of Wisconsin patients, today and tomorrow. This means we need more PAs who understand their roles in a dynamic healthcare environment and feel empowered to practice to their full license, education and training.
Please browse the questions below, organized by topic.
If you are a PA, or employ PAs, you can submit your own question by emailing the Membership & Marketing Manager Blake Manz, at firstname.lastname@example.org. Questions will be answered by the WAPA's Professional Practice Committee.
Supervising Physician Review Processes
Chapt Med 8 does not speak about a review process by site, but by supervising MD. To be clear, the review process concept is to be a discussion between supervising MD and PA to review prescribing habits and assure that the MD and PA are on the same page as far as how prescribing is done. The fact that this discussion happened is the part that needs to be documented yearly, not necessarily co-signature of charts. Here is the exact language:
"... physician assistant has had an initial and at least annual thereafter, review of the physician assistant's prescriptive practices by a physician providing supervision. Such reviews shall be documented in writing, signed by the reviewing physician and physician assistant, and made available to the Board for inspection upon reasonable request."
While this varies by employer, a reasonable way to meet this requirement is to have a yearly meeting with your supervising physician (perhaps during your yearly review or when you discuss prescribing habits, limits, preferences). You should then sign a document that attests to that meeting and discussion. This would cover you at any site and that document must be available to the board if they request it.
Currently, there is no Wisconsin statute or administrative code that requires a physician to review a specific number of PA charts. This had been a requirement in the past but it was removed in 2014.
There is a provision that the PA and supervising physician review prescribing practice - not a chart review but a yearly review to assure that the PA and supervising MD are on the same page regarding prescribing - scope of prescribing, preferred medications in certain situations) (if any, medications the MD would prefer the PA not prescribe, etc. The fact that this discussion occurred needs to be documented. A simple paper with the statement that the required yearly review of prescribing practice took place with both physician and PA signature fulfills this requirement. No chart review is required with this.
The only other co-signature requirement is for discharge summaries on hospitalized patients. This is a CMS requirement, not a Wisconsin law requirement.
Neither Wisconsin statute nor administrative code have a requirement for physician co-signature of a PAs office notes/charts. The provision specifically requiring co-signature was removed in 2009.
CMS Medicare, Medicaid and other insurers defer to state law regarding this issue. There is no requirement by any other body for physician co-signature of PA office charts/notes. Unfortunately, there no specifically documentation of this - ie; no line in the CMS manual that says "co-signature NOT required". When AAPA has specifically asked the question of CMS and other insurers, the answer is "it is not listed as a requirement, defer to state law."
The only co-signature requirements CMS Medicare that is specifically laid out is Discharge Summaries. DC summaries prepared by an provider other than a physician (including PAs, NPs, CNSs) must be co-signed by a physician. Co-signatures on H&Ps are a little less clearly defined.
Finally, sometimes the concern is around billing. There are no requirements for physician co-signature of PA notes based on billing. Even in those instances where a PA is billing "incident to" the physician, no co-signature is required. Only the specific requirements of "incident to" need to be met and co-signature is not one of them.
Specialty Practice: Podiatry
Act 227 was signed into law by Governor Walker on April 3, 2018. This bill changes several sections of Wisconsin statute to allow PAs to be supervised by podiatrists. It also redefines a Physician Assistant in Wisconsin to mean “an individual licensed by the medical examining board to provide medical care with physician supervision and direction or to practice podiatry with podiatrist supervision and direction.”
Previously, yes. This bill amends that statute to state that PAs may practice podiatry only when supervised by a podiatrist. If a PA is supervised by physician, they can only provide routine screening in podiatry. Statute 448.21(1)(d) now reads:
448.21 Physician assistants.
(1) Prohibited practices. No physician assistant may provide medical care, except routine screening, in:
(d) The practice of podiatry within the meaning of s. 448.60 (4), except when the physician assistant is acting under the supervision and direction of a podiatrist, subject to sub. (4) and the rules promulgated under s. 448.695 (4).
Currently the only details in 448.21(4) outline that a PA practicing with a podiatrist should limit their practice to non-surgical patient services. Statute 448.695(4) states that the podiatry affiliated credentialing board will make rules to establish practice standards for PAs practicing podiatry and requirements for a podiatrist who supervises a PA. Statute 448.20(3m) also states that the council on PAs will advise the podiatry affiliated credentialing board on revising practice standards for PAs practicing in podiatry.
A PA practicing with a podiatrist may issue prescriptions. The PA/podiatrist team must still complete an annual review of the PAs prescribing practice. As with PA/physician teams, this is not a chart review but a yearly review to assure that the PA and supervising podiatrist are on the same page regarding prescribing. Topics reviewed may include scope of prescribing, preferred medications in certain situations if any, medications the podiatrist would prefer the PA not prescribe, etc. The fact that this discussion occurred needs to be documented.
Each PAs scope of practice would be defined as medical care which falls within the scope of practice of the supervising podiatrist, limited to non surgical services. Acts of medical care performed for an individual patient should fall within the scope of practice of the physician or podiatrist who also cares for that patient and is supervising the PA. It is possible that the podiatry affiliated credentialing board and the council on PAs may work to define this further but as of this moment, no other definitions are in place.
Podiatrists were added to Chapter Med 8 (the administrative code governing PA practice) in all places where physicians were mentioned. Examples include:
“The podiatrist does not need to be physically present when the PA provides podiatry services.”
“The board must be notified of the changes in the supervising podiatrist within 20 days of the change.”
“The podiatrist must be available to the PA within 15 minutes by a telecommunication method.”
“A podiatrist may not supervise more than four on-duty PAs at one time.”
Yes, there are still two areas that remain a concern.
1) A PA practicing as an employee of a physician group, health care system, or hospital, is covered by the Injured Patients and Families Compensation Fund (IPFCF) for claims above their liability insurance limits. Podiatrists are required to carry liability insurance of at least $1 million per occurrence/$1 million for all occurrences in one year. Podiatrists are not named in the IPFCF, and therefore the IPFCF does not pay for claims in excess of these amounts. It is not clear that the podiatrist’s liability coverage provides coverage for claims against a PA. Nor is it clear how claims in excess of the podiatrist’s liability insurance would be covered.
A PA considering working with a podiatrist would be well advised to have a clear discussion of this issue with the practice’s legal counsel and malpractice carrier.
2) It is not clear that services performed by a PA in a podiatrist-PA relationship would be a reimbursable expense under Medicare. Currently, Medicare defines a covered service for a PA as one performed under the general supervision of and MD/DO. Podiatrists are not listed, therefore, Medicare may not consider services provided by a PA under the supervision of a podiatrist as covered.
Newly updated state statutes require healthcare providers, including PAs, to report threats to students or schools. PAs should notify a law enforcement agency immediately if they believe there is a serious and imminent threat to the health or safety of a student, school employee, or the public. Moreover, any person or institution reporting a threat, in good faith, shall have immunity from any liability, civil or criminal, that results by reason of the action.
Issues with Insurance Providers
Wisconsin State Statute 102.17(d)1 says that “Certified reports by doctors of dentistry, physician assistants, and advanced practice nurse prescribers are admissible as evidence of the diagnosis and necessity of treatment but not of the cause and extent of disability...”
Meanwhile, the Department of Workforce Development reinforces the idea that PAs can treat workmen’s comp injuries but cannot rule on fitness for work, level of disability or return-to-work limitations. Assessment in these areas requires MD co-signature for PAs and NPs alike.