Physician Assistant Collaborative Practice Arrangements

PURPOSE: This rule defines the terms used throughout this chapter as applicable to physician assistants, specifies the requirements for collaborative practice arrangements and practice of a physician assistant pursuant to a collaborative practice arrangement 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) As used in this rule, unless specifically provided otherwise, the term— (A) Collaborating 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 AND INSURANCE not so designated, may serve as a collaborating physician, upon signing a physician assistant collaborative practice arrangement for times not to exceed fifteen (15) days, when the collaborating physician is unavailable if so specified in the physician assistant collaborative practice arrangement. For the sole purpose of physician assistants practicing in federal facilities, the collaborating physician must be licensed in the state of Missouri or lawfully practicing pursuant to federal law; (B) Physician assistant collaborative practice arrangements— refers to written agreements, jointly agreed upon protocols, or standing orders between a collaborating physician and a licensed physician assistant which provide for the delegation of health care services from a collaborating physician to a licensed physician assistant and the review of such services; (C) Consultation—shall mean the process of seeking a collaborating physician’s input and guidance regarding patient care including, but not limited to, the methods specified in the physician assistant collaborative practice arrangement; (D) Assistance—shall mean participation by a collaborating physician in patient care; (E) Intervention—refers to the direct management of a patient’s care by a collaborating physician; and (F) Actively engaged—as used in subsection (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. (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 collaborative practice arrangement. A physician assistant shall not practice until informing the board, in writing, of the collaborating physician’s name and practice address(es). (3) Upon entering into a physician assistant collaborative practice arrangement, the collaborating physician shall be familiar with the level of skill, training, and the competence of the licensed physician assistant with whom the physician will be collaborating. The provisions contained in the physician assistant collaborative practice arrangement between the licensed physician assistant and the collaborating 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. (4) The delegated health care services provided for in the physician assistant collaborative practice arrangement shall be consistent with the scopes of practice of both the collaborating physician and licensed physician assistant including, but not limited to, any restrictions placed upon the collaborating physician’s practice or license. (5) The physician assistant collaborative practice arrangement between a collaborating physician and a licensed physician assistant shall— (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 collaborating physician is not continuously present; (B) Include the method and frequency of review of the licensed physician assistant’s practice activities; (C) Be reviewed at least annually and revised as the collaborating physician and licensed physician assistant deem necessary; (D) Be maintained by the collaborating physician and licensed physician assistant for a minimum of eight (8) years after the termination of the agreement; (E) Be signed and dated by collaborating physician(s) and licensed physician assistant prior to its implementation; and (F) Contain the mechanisms for input for serious or significant changes to a patient. (6) The collaborating physician shall complete a review of ten percent (10%) of the total health care services delivered by the physician assistant. If the physician assistant practice includes the prescribing of controlled substances, the physician shall review a minimum of twenty percent (20%) of the cases in which the physician assistant wrote a prescription for a controlled substance. If the controlled substance chart review meets the minimum total ten percent (10%) as described above, then the minimum review requirements have been met. The physician assistant’s documentation shall be submitted for review to the collaborating physician at least every fourteen (14) days. This documentation submission may be accomplished in person or by other electronic means and reviewed by the collaborating physician. The collaborating physician must produce evidence of the chart review upon request of the Missouri State Board of Registration for the Healing Arts. If a collaborative practice arrangement is used in clinical situations where a physician assistant provides health care services that include the diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the collaborating physician shall be present for sufficient periods of time, at least once every two (2) weeks, except in extraordinary circumstances that shall be documented, to participate in such review and to provide necessary medical direction, medical services, consultations, and supervision of the health care staff. If the physician assistant is utilizing telehealth in providing services, the collaborating physician may be present in person or the collaboration may occur via telehealth in order to meet the requirements of this section. Telehealth providers shall obtain patient’s or the patient’s guardian’s consent before telehealth services are initiated and shall document the patient’s or the patient’s guardian’s consent in the patient’s file or chart. All telehealth activities must comply with the requirements of the Health Insurance Portability and Accountability Act of 1996, as amended, and all other applicable state and federal laws and regulations. (7) Pursuant to section 630.875, RSMo, a physician assistant collaborating with a physician who is waiver-certified for the use of buprenorphine 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 physician assistant shall be considered to be on-site for the purposes of IATOAP. (8) 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 collaborating 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. 2024.* 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. ** Emergency amendment filed April 4, 2022, effective April 18, 2022, expired June 29, 2022. Amended: Filed Nov. 9, 2021, effective June 30, 2022. Amended: Filed March 25, 2025, effective Oct. 30, 2025. *Original authority: 334.735, RSMo 1989, amended 1996, 1997, 1998, 2005, 2007, 2008, 2009, 2010, 2013, 2014, 2017, 2018, 2019, 2023. **Pursuant to Executive Order 21-07, 20 CSR 2150-7.135, subsection (8)(C) was suspended from April 3, 2020 through April 23, 2021 and subsection (8)(C) and sections 190.094.1 and 2, and 190.105.2, RSMo was suspended from April 9, 2020 through April 23, 2021. 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 1507.100(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.