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Scope of Practice Frequently Asked Questions 



Q. Can a PA order restraints and/or seclusion?




Two entities regulate this issue: the federal Centers for Medicare and Medicaid Services (CMS) and the state of Michigan's laws regarding restraints and seclusion.  Generally speaking, the answer is "yes" in emergency situations and as defined for the following applications and venues:


Federal Law: The CMS has previously issued (1/8/07) final regulations that clarify when a PA may order patient restraint or seclusion as a physician-delegated responsibility, only if such delegation is allowed by state law and hospital policy.  This final rule states: "The use of restraint or seclusion must be in accordance with the order of the physician or other licensed independent practitioner (LIP) who is responsible for the care of the patient and specified under (federal law) Section 482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with state law."


State Law: The laws in Michigan regarding restraints and seclusion are found in the Public Health Code and the Mental Health Code.


The Mental Health Code (sections 330.1740-1742) stipulates that a physician shall be contacted.  It provides that a resident (in a mental health facility) may be temporarily restrained for a maximum of 30 minutes without an order or authorization in an emergency.  Immediately after imposition of the temporary restraint, however, a physician shall be contacted.  If, after being contacted, the physician does not order or authorize the restraint, the restraint shall be removed.


Also, a resident may be restrained prior to examination pursuant to an authorization by a physician.  An authorized restraint may continue only until a physician can personally examine the resident.  Seclusion may be temporarily employed using the same criteria.


The Public Health Code (section 333.20201) says that a patient or resident (in a hospital) is entitled to be free from physical and chemical restraints, except those restraints authorized in writing by the attending physician.  These restraints may only be applied for a specified and limited time.  In an emergency situation where restraints are needed to protect the patient or resident from injury to self or others, the restraint may only be applied by a qualified professional (in this case a PA).  The circumstances surrounding this action must be documented in writing and promptly reported to the attending physician.  In case of a chemical restraint, a physician shall be consulted within 24 hours after the commencement of the chemical restraint.


Child Care Organizations laws also allow a Licensed Practitioner (PA who has been "trained in the use of personal restraint and seclusion and knowledgeable of the risks inherent in the implementation of personal restraint and seclusion" to utilize these measures.


Q.Can a PA perform an abortion?




Michigan law provides that only a physician shall perform an abortion.  However, under section MCL 333.17015, a physician assistant is defined as a "qualified person assisting the physician."  This "assistance" of a PA is further limited by Michigan's Administrative Rules (R333.2304) stating that "a delegating physician shall not delegate the prescription of a drug or device individually, in combination, or in succession for a woman known to be pregnant with the intention of causing either a miscarriage or fetal death."


Q. Can a PA perform x-rays, ultrasound and other imaging procedures?




As with most specialties, these procedures can be performed by a PA only if the PA has the necessary clinical scope of practice (radiology) training.


There are a number of training programs and certification processes for physicians and ATCs that can be accessed by PAs.  The ability for a PA to practice within their scope of practice allows the PA to take courses offered by other professional disciplines and apply their acquired knowledge and techniques to the PA's practice.


Q. Can a PA pronounce death?




A PA is allowed to pronounce a person's death as part of their medical diagnosis and scope of practice.


Q. Can a PA sign a death certificate?


No.  Only a physician is allowed under state law (MCL 333.2843) to sign a death certificate.


Q. Can a PA treat conditions related to the eye?


Conditions apply.  


Michigan Law (MCL 17074) prohibits PAs from performing "acts, tasks, or functions to determine the refractive state of the human eye or to treat refractive anomalies of the human eye, or both."  


It also does not allow PAs to "determine the spectacle or contact lens prescription specifications to treat refractive anomalies of the human eye, or determine modification of spectacle or contact lens prescription specifications, or both." 


Beyond these prohibitive services that protect the scope of practice of optometrists and opticians, MCL 333.17074(3) permits PAs to "perform routine visual screening or testing, postoperative care, or assistance in the care of medical disease of the eye under a practice agreement."


Q. Can a PA perform anesthesia or conscious sedation?




Anesthesia and Endoscopic Procedures deserve some special attention.  It is generally accepted that anesthesia is a very complex procedure that requires specific training in that field.  For this reason, many PAs opt to augment their training as a physician assistant by becoming Anesthesia Assistants.  Conscious sedation, on the other hand, is well within the scope of practice of a PA and utilized in procedures such as colonoscopies and interventional radiology procedures.


Q. Can a PA perform a colonoscopy or flexible sigmoidoscopy?




Currently, Michigan Rule 325.3802 specifies that endoscopic procedures performed in a surgical outpatient facility are defined as "surgery" and can only be performed by a "physician."  Some would argue that the term "physician" includes physician assistants by virtue of delegation; however, others argue that the law clearly specified that a physician could only perform this task.  There is no similar provision relating to this practice in a hospital, which would not prevent these procedures from taking place in a hospital setting.


Q. Is there any general statement in law about a PA's scope of practice?




According to Michigan law (MCL 333.17074), "a physician's assistant shall not undertake or represent that he or she is qualified to undertake provision of medical care services that he or she knows or reasonably should know to be outside his or her competence or is prohibited by law."


Q. Can a PA perform physical therapy?




The term "physical therapy" is protected by law.  According to MCL 333.17820, "A person shall not engage in the practice of physical therapy unless licensed.."  A physician assistant may perform other physical medicine procedures, like osteopathic manipulation (under the supervision of an osteopathic physician), etc., as long as it is not deemed "physical therapy."


Q. Can a PA make patient referrals to physical therapy?




Up until recently, a PA was not allowed to refer patients to a physical therapist, but the law was changed in 2005 to allow these referrals.


Q. Can a PA order an MRI?




PAs are able to write for all studies including MRIs without a physician signature.  The issue has arisen that third party payers are interested in tracking the utilization of MRIs, and the institutions that perform them need a physician's name to assign the ordered study to.  It does not require a physician's signature.


Q. Can a PA perform osteopathic manipulative therapy?




A PA can perform osteopathic manipulative therapy (OMT) if the PA was taught or received training for this therapy and is supervised by a DO who is able to perform OMT themselves; under our delegatory laws, PAs would be able to perform OMT and bill for this service, if it is covered by the patient's insurance.


Q. What procedures require a first assistant?


No procedures require a PA as first assistant.


PAs first assisting at surgery are reimbursed by Medicare at 85% of the first-assisting fee paid to a physician (16%), or 13.6%.  PAs cannot act as primary surgeons, but they are eligible for reimbursement for first assisting in any procedure where a physician would receive such a reimbursement.  PAs are also covered when performing minor surgical procedures.


PAs should bill for their services at the full physician fee schedule, using the (-AS) modifier.  The use of the PA's NPI number and the surgical assistant billing modifier (-AS) will indicate to the Medicare carrier to implement the appropriate discount.  See Medicare Claims Processing Manual, Chapter 12, Section 110.3.  Some MACs are asking for both the 80 and AS modifiers. 


Medicare maintains a list of approximately 1,900 Current Procedure Terminology (CPT) codes for which a first assistant at surgery will not be reimbursed.  For these codes, Medicare determined that a first assistant is not needed and will not pay for the services of any medical professional acting as a first assistant.  Note: this list applies to all providers who first assist - physicians, PAs, and NPs.  If a physician deems that a first assistant is medically needed, and Medicare agrees, Medicare may grant an exception and reimburse for that service.  The op note must reflect the medical necessity and contribution of the first assistant.  There is allowance for the discretion of the surgeon to determine necessity.  Document necessity with phrases such as "the skills of [name of PA] were necessary for the successful completion of the case," "due to the complexity of the case, a first assistant was deemed necessary," "due to the patient's morbid obesity with a BMI greater than 40 and resultant complexity of the case, the assistance of the PA was essential."


Q. Can a PA prescribe physical therapy, speech therapy, occupational therapy, etc.?




There are no restrictions in Michigan law limiting this.

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