The PMA Identity Crisis: Where Do We Go From Here?
I recently lectured at two different seminars in which the discussion among assistants went down a very similar path. The overwhelming majority of assistants in attendance did not feel it was their place to perform anything invasive. In fact, one assistant questioned the legality of allowing a PMA to perform services from a billing perspective. The assistant asked, “How can the doctor bill for something he or she did not actually do?” This elicited a response from another assistant who stated that “bills are being generated for strapping and casting procedures not performed by the physician. How is that any different?” Sandra Lohrentz, PMAC, Executive Director of the ASPMA, offered a pamphlet, “Detailed Responsibilities of Certified Podiatric Medical Assistants,” which states, “If the procedure has a surgical code, the (certified) PMA should not perform the task. The podiatric physician/surgeon is the one getting paid for the surgical procedures. Thus, the physician must perform that procedure.” While this would seem straightforward, some still argue that the application of an adhesive strapping (while not invasive) carries a surgical code (29540). Is it or is it not acceptable for an assistant to perform this procedure? Ira Kraus, DPM, of Chattanooga, Tenn. points out there are some Medicare local coverage policies (LCP) that could possibly restrict an assistant from administering physical therapy or performing vascular studies. He recommends that, prior to performing these tests, one should review carrier LCPs or check with the local CAC representative. Assessing The Radiology Exception In an effort to research what (if any) laws exist to this end, I have enlisted the help of some knowledgeable individuals within our profession. The executive directors of the Washington, Ohio, New York, Illinois and North Carolina Podiatric Medical Societies and the New Jersey Office of the Attorney General provided valuable information. Each one acknowledged this is a “huge gray area” in our profession. They offered to help by sharing what they knew of their individual state regulations but most conceded there is nothing written that specifically addresses what a PMA can and cannot do. All of these folks unanimously agreed that radiology was the exception. Each of them recognized that certain requirements do exist (however divergent) from state to state with regard to taking X-rays. Having undergone approximately 120 hours of didactic and 80 hours of clinical study to get my required podiatric radiology technologist (PRT) license, which New Jersey legally requires in order to take limited foot and ankle X-rays, I was very familiar with the unbalanced regulations nationwide. Given these extreme variations, I will never understand why some states require stringent controls (and even licensing) to take X-rays while others require nothing more than a minimal hour course. In Washington, you need only take an eight-hour AIDS course to authorize taking X-rays. Don’t ask. Shouldn’t radiology safety be the same everywhere? Why the disparity? A Closer Look At The Existing Documentation On Assistant Duties Susan Scanlan, DPM, the Executive Director of the Washington State Podiatric Medical Association (WSPMA), directed me to a Department of Health Web site to read WAC 246-922-100: Acts that may be delegated to an unlicensed person. This was a great start. They also utilize the common verbiage, “… duties may be performed only under the supervision of a licensed podiatric physician and surgeon.” However, they also provide a laundry list of acceptable tasks that non-licensed personnel can do which includes (but is not limited to): • patient education in foot hygiene; • deliver a sedative drug in a oral dosage form to the patient; • give preoperative and postoperative instructions; • take health histories; • measure the patient’s blood pressure; • perform a plethysmographic or Doppler study; • assist in obtaining material for a C&S test; • take scrapings from the skin or nails of the feet; • debride keratotic tissues of the foot; • remove and apply dressings and/or padding; • produce impression casting of the foot; • “prepare” the foot for anesthesia as needed; • apply a flexible cast (e.g., unna boot); • apply cast material for immobilization of foot and leg; and • remove sutures, debride nails and other instructional protocols.