The PMA Identity Crisis: Where Do We Go From Here?
Is There Any Clarity About What Constitutes ‘Invasive’ Procedures?
Clearly, the majority of doctors I have questioned have expressed extreme opposition to allowing an assistant to perform any “invasive” procedure. Most say that assistants simply are not licensed to do so no matter how much “hands-on” training they have received in the practice. In fact, some admit they are even apprehensive delegating suturing to qualified hospital personnel.
John Guiliana, DPM, a practice management consultant based in Hackettstown, NJ, agrees that the line of delegation is gray. He admits that distinguishing right from wrong should be based upon one's own value system as well as decisions based upon reason. His own personal decision of where to draw the line is based upon “invasiveness.” He feels there are three components of surgery: opening/dissection, wound closure and postoperative bandaging and care. Dr. Guiliana states that he could not, in clear conscience, delegate any of the invasive components of this process to non-licensed individuals.
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?