PURPOSE: This rule defines the terms used throughout this chapter as applicable to physician assistants, specifies the requirements for supervision agreements and practice of a physician assistant pursuant to a supervision agreement pursuant to section 334.735, RSMo, and physician assistant involvement in the “Improved Access to Treatment for Opioid Addictions Act” (IATOA) pursuant to section 630.875, RSMo.

1. (1) As used in this rule, unless specifically provided otherwise, the term—

   1. (A) Supervising physician—shall mean a physician who holds a permanent license to practice medicine in the state of Missouri and who is actively engaged in the practice of medicine, except that this shall not include physicians who hold a limited license pursuant to section 334.112, RSMo, or a temporary license pursuant to section 334.045 or 334.046, RSMo, or physicians who have retired from the practice of medicine. A physician meeting these requirements, but not so designated, may serve as a supervising physician, upon signing a physician assistant supervision agreement for times not to exceed fifteen (15) days, when the supervising physician is unavailable if so specified in the physician assistant supervision agreement. For the sole purpose of physician assistants practicing in federal facilities, the supervising physician must be licensed in the state of Missouri or lawfully practicing pursuant to federal law;
   2. (B) Physician assistant supervision agreements—refers to written agreements, jointly agreed upon protocols, or standing orders between a supervising physician and a licensed physician assistant which provide for the delegation of health care services from a supervising physician to a licensed physician assistant and the review of such services;
   3. (C) Consultation—shall mean the process of seeking a supervising physician’s input and guidance regarding patient care including, but not limited to, the methods specified in the physician assistant supervision agreement;
   4. (D) Assistance—shall mean participation by a supervising physician in patient care;
   5. (E) Intervention—refers to the direct management of a patient’s care by a supervising physician; and
   6. (F) Actively engaged—as used in subsection FINANCIAL INSTITUTIONS AND PROFESSIONAL REGISTRATION

(1)(A) of this rule shall mean a physician who, in addition to the patients being treated by the physician assistant, has an established practice of patients for whom they are responsible for their ongoing care.

1. (2) No physician assistant shall practice pursuant to the provisions of sections 334.735 through 334.748, RSMo, or to the provisions of this rule unless licensed and pursuant to a written physician assistant supervision agreement. A physician assistant shall not practice until informing the board, in writing, of the supervising physician’s name and practice address(es).
2. (3) Upon entering into a physician assistant supervision agreement, the supervising physician shall be familiar with the level of skill, training, and the competence of the licensed physician assistant whom the physician will be supervising. The provisions contained in the physician assistant supervision agreement between the licensed physician assistant and the supervising physician shall be within the scope of practice of the licensed physician assistant and consistent with the licensed physician assistant’s skill, training, and competence.
3. (4) The delegated health care services provided for in the physician assistant supervision agreement shall be consistent with the scopes of practice of both the supervising physician and licensed physician assistant including, but not limited to, any restrictions placed upon the supervising physician’s practice or license.

4. (5) The physician assistant supervision agreement between a supervising physician and a licensed physician assistant shall—

   1. (A) Include consultation, transportation, and referral procedures for patients needing emergency care or care beyond the scope of practice of the licensed physician assistant if the licensed physician assistant practices in a setting where a supervising physician is not continuously present;
   2. (B) Include the method and frequency of review of the licensed physician assistant’s practice activities;
   3. (C) Be reviewed at least annually and revised as the supervising physician and licensed physician assistant deem necessary;
   4. (D) Be maintained by the supervising physician and licensed physician assistant for a minimum of eight (8) years after the termination of the agreement;
   5. (E) Be signed and dated by the supervising physician, alternate supervising physician(s), and licensed physician assistant prior to its implementation; and
   6. (F) Contain the mechanisms for input for serious or significant changes to a patient.
5. (6) In addition to administering and dispensing controlled substances, a physician assistant, who meets the requirements of 20 CSR 2150- 7.130, may be delegated the authority to prescribe controlled substances listed in Schedules II (hydrocodone), III, IV, and V of section 195.017, RSMo, in a written supervision agreement, except that, the supervision agreement shall not delegate the authority to administer any controlled substances listed in Schedules II (hydrocodone), III, IV, and V of section 195.017, RSMo, for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. When issuing the initial prescription for an opioid controlled substance in treating a patient for acute pain, the physician assistant shall comply with requirements set forth in section 195.080, RSMo. Schedule II (hydrocodone) and Schedule III narcotic controlled substance prescriptions shall be limited to a five- (5-) day supply without refill. Pursuant to section 334.747, RSMo, a physician assistant may prescribe Schedule III buprenorphine for up to a thirty- (30-) day supply without refill for patients receiving medication-assisted treatment for substance abuse disorders under the direction of the collaborating physician as described in sections 334.735 and 630.875, RSMo.
6. (7) It is the responsibility of the supervising physician to determine and document the completion of a one- (1-) month period of time during which the licensed physician assistant shall practice with a supervising physician continuously present before practicing in a setting where a supervising physician is not continuously present. A one- (1-) month period shall consist of a minimum of one hundred (100) hours in a consecutive thirty- (30-) day period.

7. (8) The following shall apply in the use of a supervision agreement by a physician assistant who provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons:

   1. (A) If the collaborating physician and physician assistant are utilizing telehealth in providing services in medically underserved area as defined in 20 CSR 2150-2.001(11), no mileage limitation shall apply;
   2. (B) If the physician assistant is providing services pursuant to section 334.735.2(2), RSMo, no supervision requirements in addition to the minimum federal law shall be required;
   3. (C) If the collaborating physician and physician assistant are not utilizing telehealth in providing services in the medically underserved area, the practice location where the collaborating physician, or other physician designated in the collaborative practice agreement, shall be no further than seventy-five

8. (75) miles by road, using the most direct route available, from the collaborating physician assistant;

   1. (D) If the physician assistant is collaborating with a physician who is waiver-certified for the use of buprenorphine, pursuant to section 630.875 RSMo, the physician assistant may participate in the “Improved Access to Treatment for Opioid Addictions Program” (IATOAP) in any area of the state and provide all services and functions of a physician assistant. A remote collaborating physician working with an on-site APRN shall be considered to be on-site for the purposes of IATOAP.
9. (9) Pursuant to section 334.104, RSMo, a supervising physician shall not enter into a collaborative practice arrangement or supervision agreement with more than six (6) fulltime equivalent APRNs, full-time equivalent physician assistants, full-time equivalent assistant physicians, or any combination thereof. This limitation shall not apply to collaborative arrangements of hospital employees providing inpatient care service in hospitals as defined in Chapter 197, RSMo, or population-based public health services as defined in this rule or to a certified registered nurse anesthetist providing anesthesia services under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed as set out in section 334.104(7), RSMo.
10. (10) It is the responsibility of the supervising physician and licensed physician assistant to jointly review and document the work, records, and practice activities of the licensed physician assistant at least once every two (2) weeks. The supervising physician must review a minimum of ten percent (10%) of the physician assistant’s patients’ records every two (2) weeks and have documentation supporting the review. For nursing home practice, such review shall occur at least once a month. The documentation of this review shall be available to the Board of Registration for the Healing Arts for review upon request.
11. (11) If any provisions of these rules are deemed by the appropriate federal or state authority to be inconsistent with guidelines for federally funded clinics, individual provisions of these rules shall be considered severable and supervising physicians and licensed physician assistants practicing in such clinics shall follow the provisions of such federal guidelines in these instances. However, the remainder of the provisions of these rules not so affected shall remain in full force and effect for such practitioners.

AUTHORITY: section 334.735, RSMo Supp. 2018.* This rule originally filed as 4 CSR 150-7.135. Original rule filed Jan. 3, 1997, effective July 30, 1997. Rule Action Notice filed: July 7, 1998, effective July 21, 1999. Amended: Filed July 30, 1999, effective Feb. 29, 2000. Amended: Filed March 1, 2005, effective Aug. 30, 2005. Amended: Filed June 1, 2005, effective Dec. 30, 2005. Moved to 20 CSR 2150-7.135, effective Aug. 28, 2006. Emergency amendment filed Oct. 19, 2007, effective Oct. 29, 2007, expired April 25, 2008. Amended: Filed Oct. 19, 2007, effective May 30, 2008. Amended: Filed April 3, 2009, effective Sept. 30, 2009. Amended: Filed Nov. 1, 2010, effective June 30, 2011. Amended: Filed Dec. 11, 2017, effective June 30, 2018. Emergency amendment filed Feb. 22, 2019, effective March 4, 2019, expired Aug. 30, 2019. Amended: Filed Feb. 22, 2019, effective Aug. 30, 2019.

*Original authority: 334.735, RSMo 1989, amended 1996, 1997, 1998, 2005, 2007, 2008, 2009, 2010, 2013, 2014, 2017, 2018. Rule Action Notice: On July 16, 1999, the Cole County Circuit Court, Case No. CV198-196CC, ordered that the definition of “same office facility” set forth in 4 CSR 150- 7.135(1)(F) be terminated from the rule as being promulgated without statutory rulemaking authority. The Court further ordered the suspension of the following sections of the rule: the portion of subsection (1)(E) which states “either personally or via telecommunications”; the portion of section (3) which states “either personally or via telecommunications”; the portion of section (4) which states “A physician assistant shall be limited to practice locations where the supervising physician as designated pursuant to 4 CSR 150-7.100(4) or otherwise in the physician assistant supervision agreement, is no further than thirty (30) miles by road, using the most direct route available, or in any other fashion so distanced as to create an impediment to effective intervention, supervision of patient care or adequate review of services.”; the portion of section (7) which states “as defined in subsection (4)(F)”; and section (10) in its entirety. The Judgment and Order of the Court was entered on July 6, 1999. The Court provided that the effective date of the voiding of 4 CSR 150-7.135(1)(F), and the suspension of portions of 4 CSR 150- 7.135(1)(E), (3), (4), (7), and 4 CSR 150- 7.135(10) shall be fifteen (15) days from the entry of the Court Order. After July 21, 1999, 4 CSR 150-7.135(1)(F) shall be terminated and of no further force and effect and portions of 4 CSR 150-7.135(1)(E), (3), (4), and (7), and section (10) in its entirety shall be suspended until modified through the rulemaking process. No appeal is taken.