AN ACT relating to physician assistants.

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AN ACT relating to physician assistants. 1
Be it enacted by the General Assembly of the Commonwealth of Kentucky: 2
Section 1. KRS 311.840 is amended to read as follows: 3
As used in KRS 311.840 to 311.862: 4
(1) "Board" means the Kentucky Board of Medical Licensure; 5
(2) "Complaint" means a formal administrative pleading that sets forth charges against 6
a physician assistant and commences a formal disciplinary proceeding; 7
(3) "Physician assistant" means a person licensed under KRS 311.840 to 311.862 who: 8
(a) Has graduated from a physician assistant or surgeon assistant program 9
accredited by the Accreditation Review Commission on Education for 10
Physician Assistants or its predecessor or successor agencies and has passed 11
the certifying examination administered by the National Commission on 12
Certification of Physician Assistants or its predecessor or successor agencies; 13
or 14
(b) Possesses a current physician assistant certificate issued by the board prior to 15
July 15, 2002; 16
(4) "Supervising physician" means a physician licensed by the board who supervises 17
one (1) or more physician assistants; 18
(5) "Supervising physician in anesthesia" means a physician licensed by the board who 19
has completed postgraduate training in anesthesiology at an anesthesiology program 20
accredited by the Accreditation Council for Graduate Medical Education or its 21
equivalent; and 22
(6) "Supervision": 23
(a) Means overseeing the activities [of ] and [accepting of responsibility for the 24
]medical services rendered by a physician assistant. Each team of physic ians 25
and physician assistants shall ensure that the approved[delegation of] medical 26
tasks are[is] appropriate to the physician assistant's level of training and 27
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experience, that the identifications of and access to the supervising physician 1
are clearly def ined, and that a process for evaluation of the physician 2
assistant's performance is established; and 3
(b) Does not require the physical presence of a supervising physician when 4
medical services are rendered by a physician assistant. 5
Section 2. KRS 311.844 is amended to read as follows: 6
(1) To be licensed by the board as a physician assistant, an applicant shall: 7
(a) Submit a completed application form with the required fee; 8
(b) Be of good character and reputation; 9
(c) Be a graduate of an approved program; and 10
(d) Have passed an examination approved by the board within three (3) attempts , 11
or have been granted a waiver by the board. 12
(2) A physician assistant who is authorized to practice in another state and who is in 13
good standing may apply for licensure by endorsement from the state of his or her 14
credentialing if that state has standards substantially equivalent to those of this 15
Commonwealth. 16
(3) A physician assistant's license shall be valid for two (2) years and shall be r enewed 17
by the board upon fulfillment of the following requirements: 18
(a) The holder shall be of good character and reputation; 19
(b) The holder shall provide evidence of completion, during the previous two (2) 20
years, of a minimum of one hundred (100) hours of continuing education 21
approved by the American Medical Association, the American Osteopathic 22
Association, the American Academy of Family Physicians, the American 23
Academy of Physician Assistants, or by another entity approved by the board. 24
The one hundred ( 100) hours of continuing education required by this 25
paragraph shall include: 26
1. During the first two (2) years of licensure or prior to the first licensure 27
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renewal: 1
a. One and one -half (1.5) hours of continuing education in the 2
prevention and recognition o f pediatric abusive head trauma, as 3
defined in KRS 620.020, except that graduating physician assistant 4
students may apply pediatric abusive head trauma curriculum 5
taught in their physician assistant graduate education to count 6
towards the required one and one-half (1.5) hours; and 7
b. As a part of the continuing education requirements that the board 8
adopts to ensure continuing competency of present and future 9
licensees and the evolving needs of the growing senior population, 10
the board shall ensure physician assistants licensed under KRS 11
Chapter 311 complete a one (1) time course of one (1) hour of 12
continuing education approved by the board. The course shall be 13
completed one (1) time and count towards the current number of 14
required continuing education hours, except that graduating 15
student physician assistants may submit Alzheimer's and other 16
forms of dementia course curriculum taught in their programs of 17
study towards the required one (1) hour for approval. The course 18
topics shall include but not be limited to: 19
i. The warning signs and symptoms of Alzheimer's disease and 20
other forms of dementia; 21
ii. The importance of early detection, diagnosis, and appropriate 22
communication techniques for discussion of memory 23
concerns with the patient and his or her caregiver; 24
iii. Cognitive assessment and care planning billing codes; 25
iv. The variety of tools used to assess a patient's cognition; and 26
v. Current treatments that may be available to the patient; and 27
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2. If the license holder is authorized, pursuant to KRS 311.858(4) [KRS 1
311.858(5)], to prescribe and administer Schedule II, III, IV, or V 2
controlled substances, a minimum of seven and one -half (7.5) hours of 3
approved continuing education relating to controll ed substance 4
diversion, pain management, addiction disorders, use of the electronic 5
system for monitoring controlled substances established in KRS 6
218A.202, or any combination of two (2) or more of these subjects; and 7
(c) The holder shall provide proof of current certification with the National 8
Commission on Certification of Physician Assistants. 9
Section 3. KRS 311.850 is amended to read as follows: 10
(1) The board may revoke, suspend, deny, decline to renew, limit, or rest rict the license 11
of a physician assistant, or may fine, reprimand or place a physician assistant on 12
probation for no more than five (5) years upon proof that a physician assistant has: 13
(a) Knowingly made or presented or caused to be made or presented any f alse, 14
fraudulent, or forged statement, writing, certificate, diploma, or other 15
document relating to an application for licensure; 16
(b) Practiced, aided, or abetted in the practice of fraud, forgery, deception, 17
collusion, or conspiracy relating to an examination for licensure; 18
(c) Been convicted of a crime as defined in KRS 335B.010, if in accordance with 19
KRS Chapter 335B; 20
(d) Been convicted of a misdemeanor offense under KRS Chapter 510 involving 21
a patient or a felony offense under KRS Chapter 510, KRS 530.0 64, or 22
531.310, or has been found by the board to have had sexual contact, as 23
defined in KRS 510.010, with a patient while the patient was under the care of 24
the physician assistant or the physician assistant's supervising physician; 25
(e) Become addicted to a controlled substance, as defined in KRS 311.550(26); 26
(f) Become a chronic or persistent alcoholic, as defined in KRS 311.550(25); 27
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(g) Been unable or is unable to practice medicine according to acceptable and 1
prevailing standards of care by reason of ment al or physical illness or other 2
condition including but not limited to physical deterioration that adversely 3
affects cognitive, motor, or perceptive skills, or by reason of an extended 4
absence from the active practice of medicine; 5
(h) Knowingly made or caused to be made or aided or abetted in the making of a 6
false statement in any document executed in connection with the practice of 7
medicine or osteopathy; 8
(i) Performed any act or service as a physician assistant without a designated 9
supervising physician; 10
(j) Exceeded the scope of medical services described by the supervising 11
physician in the agreement[applications] required under KRS 311.854; 12
(k) Exceeded the scope of practice for which the physician assistant was 13
credentialed by the governing board of a h ospital or licensed health care 14
facility under KRS 311.856 and 311.858; 15
(l) Aided, assisted, or abetted the unlawful practice of medicine or osteopathy or 16
any healing art, including the unlawful practice of physician assistants; 17
(m) Willfully violated a confidential communication; 18
(n) Performed the services of a physician assistant in an unprofessional, 19
incompetent, or grossly or chronically negligent manner; 20
(o) Been removed, suspended, expelled, or placed on probation by any health care 21
facility or profes sional society for unprofessional conduct, incompetence, 22
negligence, or violation of any provision of this section or KRS 311.858 or 23
311.862; 24
(p) Violated any applicable provision of administrative regulations relating to 25
physician assistant practice; 26
(q) Violated any term of probation or other discipline imposed by the board; 27
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(r) Failed to complete the required number of hours of approved continuing 1
education; 2
(s) Engaged in dishonorable, unethical, or unprofessional conduct of character 3
likely to deceive, defraud, or harm the public or any member thereof, as 4
described in KRS 311.597; or 5
(t) As provided in KRS 311.824(2), been convicted of a violation of KRS 6
311.823(2). 7
(2) All disciplinary proceedings against a physician assistant shall be conducted in 8
accordance with the provisions of KRS 311.591, 311.592, 311.593, 311.599, and 9
KRS Chapter 13B and related administrative regulations promulgated under KRS 10
Chapter 311. 11
Section 4. KRS 311.854 is amended to read as follows: 12
(1) A physician shall not supervise a physician assistant without approval of the board. 13
Failure to obtain board approval as a supervising physician or failure to comply 14
with the requirements of KRS 311.840 to 311.862 or related administrative 15
regulations shall be considered unprofessional conduct and shall be subject to 16
disciplinary action by the board that may include revocation, suspension, 17
restriction, or placing on probation the supervising physician's rig ht to supervise a 18
physician assistant. 19
(2) To be approved by the board as a supervising physician, a physician shall: 20
(a) Be currently licensed and in good standing with the board; 21
(b) Maintain a practice primarily within this Commonwealth. The board in it s 22
discretion may modify or waive this requirement; 23
(c) Submit a completed application and the required fee to the board. The 24
application shall include but is not limited to: 25
1. A description of the nature of the physician's practice; and 26
2. A statement of assurance by the supervising physician that the scope of 27
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medical services and procedures of the physician assistant [described in 1
the application or in any supplemental information] shall not exceed the 2
normal scope of practice of the supervising physician[; 3
3. A description of the means by which the physician shall maintain 4
communication with the physician assistant when they are not in the 5
same physical location; 6
4. A description of the scope of medical services and procedures to be 7
performed by the physic ian assistant for which the physician assistant 8
has been trained in an approved program; and 9
5. An outline of the specific parameters for review of countersignatures]. 10
(3) A physician assistant shall not render any medical service or procedure unless 11
the r equired supervision agreement is completed and signed by the supervising 12
physician and physician assistant, and in effect. The supervision agreement shall 13
include[Prior to a physician assistant performing any service or procedure beyond 14
those described in the initial application submitted to the board under subsection 15
(2)(c) of this section, the supervising physician shall supplement that application 16
with information that includes] but is not limited to: 17
(a) The scope of medical services and procedures appr oved by the supervising 18
physician to be performed by the physician assistant; 19
(b) The level and method of supervision to be provided by the supervising 20
physician; 21
(c) Any applicable requirements for review and countersignature of the 22
physician assistant's medical notes, orders, or prescriptions; 23
(d) Procedures governing communications and clinical decision -making 24
between the supervising physician and the physician assistant; 25
(e) The primary practice location and any additional sites where the physician 26
assistant is authorized to provide services; and 27
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(f) Any alternate physician supervision arrangements authorized under KRS 1
311.840 to 311.862[A description of the additional service or procedure; 2
(b) A description of the physician assistant's education, traini ng, experience, and 3
institutional credentialing; 4
(c) A description of the level of supervision to be provided for the additional 5
service or procedure; 6
(d) The location or locations where the additional service or procedure will be 7
provided; and 8
(e) Any changes to the specific parameters for review of countersignatures. 9
The initial and supplemental applications required under this section may be 10
submitted to the board at the same time]. 11
(4) (a) The board shall develop and make available a standardized super vision 12
agreement form to be used by supervising physicians and physician 13
assistants. 14
(b) A copy of the completed and signed supervision agreement, and any 15
subsequent amendments, shall be furnished to and maintained on file by the 16
board and shall be maintained, in a readily accessible physical or electronic 17
form, at the primary practice location where the physician assistant provides 18
patient care. 19
(5) The supervision agreement may be amended at any time upon the mutual 20
agreement of the supervising physician and physician assistant. All amendments 21
shall be submitted to the board and maintained in accordance with this section. 22
(6) A licensed health care f acility utilizing alternate supervising physicians may 23
satisfy the filing requirements of this section through an alternative filing method 24
approved by the board. Compliance with a board -approved alternative filing 25
method shall be deemed compliant with the filing and amendment requirements 26
of this section. 27
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(7) A licensed health care facility may designate one (1) or more physicians to serve 1
as alternate supervising physicians for the purpose of providing supervision to 2
one (1) or more physician assistants w hen the primary supervising physician is 3
unavailable. A health care facility's designation of alternate supervising 4
physicians may be structured to allow for rotating, shift -based, or department -5
based supervision, provided that all supervising physicians: 6
(a) Are licensed and in good standing with the board; 7
(b) Have been designated in the applicable supervision agreement described in 8
this section; and 9
(c) Fulfill the responsibilities of a supervising physician under this section and 10
Section 5 of this Act. 11
(8) A supervision agreement shall not be required to name an alternate supervising 12
physician. Alternate supervising physician designations shall comply with 13
administrative regulations promulgated by the board in accordance with KRS 14
Chapter 13A and the supervision agreement. 15
(9)[(4)] A physician who has been supervising a physician assistant prior to July 15, 16
2002, may continue supervision and the physician assistant may continue to 17
perform all medical services and procedures that were provided by the physic ian 18
assistant prior to July 15, 2002. The supervising physician shall submit the initial 19
application and any supplemental application as required in this section by October 20
15, 2002. 21
(10)[(5)] A physician may enter into supervision agreements with no more than four (4) 22
physician assistants and shall not supervise more than four (4) physician assistants 23
at any one (1) time. Application for board approval to be a supervising physician 24
shall be obtained individually for each physician assistant. 25
(11) The board shall promulgate administrative regulations in accordance with KRS 26
Chapter 13A to implement and enforce this section, including: 27
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(a) Procedures for the submission, review, modification, and re newal of 1
supervision agreements; and 2
(b) Alternative filing methods for licensed health care facilities to utilize 3
alternate supervising physicians[(6) The board may impose restrictions on 4
the scope of practice of a physician assistant or on the methods of supervision 5
by the supervising physician upon consideration of recommendations of the 6
Physician Assistant Advisory Committee established in KRS 311.842 after 7
providing the applicant with reasonable notice of its intended action and after 8
providing a reasonable opportunity to be heard]. 9
Section 5. KRS 311.856 is amended to read as follows: 10
A supervising physician shall: 11
(1) Restrict the services of a physician assistant to services within the physician 12
assistant's scope of practice and to the provisions of KRS 311.840 to 311.862; 13
(2) Prohibit a physician assistant from dispensing controlled substances; 14
(3) Prohibit a physician assistant from prescribing or administering controlled 15
substances, except as provided in KRS 311.858(4)[KRS 311.858(5)]; 16
(4) [Inform all patients in contact with a physician assistant of the status of the 17
physician assistant; 18
(5) Post a notice stating that a physician assistant practices medicine or osteopathy in 19
all locations where the physician assistant may practice; 20
(6) ]Require a physician assistant to wear identification that clearly states that he or she 21
is a physician assistant; 22
(5)[(7)] Prohibit a physician assistant from independently billing any patient or other 23
payor for services rendered by the physician assistant; 24
(6)[(8)] If necessary, participate with the governing body of any hospital or other 25
licensed health care facility in a credentialing process established by the facility; 26
(7)[(9)] Not require a physician assistant to perform servi ces or other acts that the 27
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physician assistant feels incapable of carrying out safely and properly; 1
(8)[(10)] Maintain [adequate, active, and continuous ] supervision as outlined in the 2
supervision agreement requirement described in Section 4 of this Act [of a 3
physician assistant's activities] to ensure[assure] that the physician assistant is 4
performing as directed and complying with the agreement[requirements of KRS 5
311.840 to 311.862 and all related administrative regulations; 6
(11) Review and countersign a sufficient number of overall medical notes written by the 7
physician assistant to ensure quality of care provided by the physician assistant and 8
outline the specific parameters for review of countersignatures in the application 9
required by KRS 311.854. Coun tersignature requirements shall be determined by 10
the supervising physician, practice, or institution. As used in this subsection: 11
(a) "Practice" means a medical practice composed of two (2) or more physicians 12
organized to provide patient care services, reg ardless of its legal form or 13
ownership; and 14
(b) "Institution" means all or part of any public or private facility, place, building, 15
or agency, whether organized for profit or not, that is used, operated, or 16
designed to provide medical diagnosis, treatment, nursing, rehabilitative, or 17
preventive care; 18
(12) (a) Reevaluate the reliability, accountability, and professional knowledge of a 19
physician assistant two (2) years after the physician assistant's original 20
licensure in this Commonwealth and every two (2) years thereafter; and 21
(b) Based on the reevaluation, recommend approval or disapproval of licensure or 22
renewal to the board]; and 23
(9)[(13)] Notify the board within three (3) business days if the supervising physician: 24
(a) Ceases to supervise or employ the physician assistant; or 25
(b) Believes in good faith that a physician assistant violated any disciplinary rule 26
of KRS 311.840 to 311.862 or related administrative regulations. 27
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Section 6. KRS 311.858 is amended to read as follows: 1
(1) A physician assistant may perform medical se rvices and procedures within the 2
scope of medical services and procedures described in the supervision 3
agreement[initial or any supplemental application received by the board] under 4
KRS 311.854. 5
(2) [A physician assistant shall be considered an agent of th e supervising physician in 6
performing medical services and procedures described in the initial application or 7
any supplemental application received by the board under KRS 311.854. 8
(3) ]A physician assistant may initiate evaluation and treatment in emergency situations 9
without specific approval. 10
(3)[(4)] A physician assistant may prescribe and administer all nonscheduled legend 11
drugs and medical devices to the extent approved[delegated] by the supervising 12
physician. A physician assistant who is approved and has[delegated] prescribing 13
authority may request, receive, sign for, and distribute professional samples of 14
nonscheduled legend drugs to patients. 15
(4)[(5)] (a) A physician assistant who has bee n approved by the board pursuant to 16
paragraph (b) of this subsection, may prescribe and administer Schedules II, 17
III, IV, and V controlled substances, as described in KRS Chapter 218A, to 18
the extent approved[delegated] by the supervising physician and as p ermitted 19
under paragraphs (c), (d), [and ](e), and (f) of this subsection. 20
(b) Before a physician assistant engages in prescribing or administering 21
controlled substances, the physician assistant shall: 22
1. Have at least one (1) year of experience as a licen sed and practicing 23
physician assistant; 24
2. Submit to the board a completed application for prescriptive authority 25
for controlled substances signed by the physician assistant's supervising 26
physician in accordance with KRS 311.856; 27
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3. Receive from the board, or its executive director, a notice that the 1
application for prescriptive authority has been approved; and 2
4. Obtain a Controlled Substance Registration Certificate through the 3
United States Drug Enforcement Administration and register with the 4
electronic system for monitoring controlled substances established in 5
KRS 218A.202 and any other applicable state controlled substance 6
regulatory authority. 7
(c) Prescriptions issued by a physician assistant for narcotic Schedule II 8
controlled substances classified u nder KRS 218A.060, except for 9
hydrocodone combination products as defined in KRS 218A.010, shall be 10
limited to a seventy-two (72) hour supply without any refill. 11
(d) Prescriptions issued by a physician assistant for hydrocodone combination 12
products as defi ned in KRS 218A.010, nonnarcotic Schedule II controlled 13
substances, and Schedule III controlled substances, as defined[described] in 14
KRS 218A.060 and 218A.080, shall be limited to a thirty (30) day supply 15
without any refill. 16
(e)[(d)] Prescriptions issued b y a physician assistant for Schedule IV or V 17
controlled substances, as defined[described] in KRS 218A.100 and 218A.120, 18
shall be limited to the original prescription and refills not to exceed a six (6) 19
month supply. 20
(f)[(e)] Notwithstanding paragraph (e)[(d)] of this subsection, prescriptions 21
issued by a physician assistant for benzodiazepines or Carisoprodol shall be 22
limited to a thirty (30) day supply without any refill. 23
(5)[(6)] A physician assistant shall not submit direct billing for medical services a nd 24
procedures performed by the physician assistant. 25
(6)[(7)] A physician assistant may perform local infiltrative anesthesia under the 26
provisions of subsection (1) of this section, but a physician assistant shall not 27
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administer or monitor general or region al anesthesia unless the requirements of 1
KRS 311.862 are met. 2
(7)[(8)] A physician assistant may perform services in the offices or clinics of the 3
supervising physician. A physician assistant may also render services in hospitals or 4
other licensed health c are facilities only with written permission of the facility's 5
governing body, and the facility may restrict the physician assistant's scope of 6
practice within the facility as deemed appropriate by the facility. 7
(8)[(9)] A physician assistant shall not practice medicine or osteopathy independently. 8
Each physician assistant shall practice under a supervision agreement as described 9
in Section 4 of this Act[defined in KRS 311.840]. 10
Section 7. KRS 186.577 is amended to read as follows: 11
(1) (a) The following persons shall submit to a test of visual acuity and visual field at 12
the time of application or renewal: 13
1. All persons applying for an initial or renewal operator's license; 14
2. All persons applying for an initial or renewal instruction permit; and 15
3. Any person required to complete an examination under KRS 186.635. 16
(2) Vision testing under this section shall be administered to any person: 17
(a) Applying for an initial operator's license, an initial instruction permit, or 18
reinstatement of a license when vision must be tested as required in KRS 19
186.480: 20
1. Prior to the time of application under subsection (5) of this section; or 21
2. By the Department of Kentucky State Police at the time of application; 22
(b) Applying for operator's license renewal or instruction permit renewal: 23
1. Prior to the time of application under subsection (5) of this section; or 24
2. By the Transportation Cabinet at the time of application; or 25
(c) Identified in Kentucky administrative regulations promulgated by the 26
Transportation Cabinet or the Department of Kentucky State Police as being 27
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required to undergo the exam required by KRS 186.480. 1
(3) (a) Persons whose visual acuity is 20/40 or better and who meet or exceed the 2
visual field standard established by the Transportation Cabinet without 3
corrective lenses shall not have a restriction placed on their driving privileges. 4
(b) Persons whose visual acuity is 20/40 or better and who meet or exceed the 5
visual field standard established by the Transportation Cabinet with corrective 6
lenses shall have their driving privileges restricted to mandate the use of the 7
corrective lenses. 8
(c) If a person fails to meet a 20/40 visual acuity standard or the visual field 9
standard established by the cabinet, the person shall be referred to a vision 10
specialist for examination. 11
(4) A person referred to a vision specialist under subsection (3) of this section whose 12
visual acuity is 20/60 or better and who meets or exceeds the visual field standard 13
established by the cabinet shall be eligible to test for an instruction permit or 14
operator's license, or shall be eligible for operator's license renewal. If corrective 15
lenses were prescribed by the vision specialist, the person's driving privileges shall 16
be restricted to mandate the use of the corrective lenses. 17
(5) Vision tests administered under subsection (2)(a) of this section shall be deemed to 18
meet the testing provisions o utlined in subsection (3) or (4) of this section, if the 19
person submits a driver vision testing form that complies with the provisions of 20
subsection (6) of this section and the form has been completed by: 21
(a) A vision specialist; or 22
(b) An osteopath, physi cian, physician assistant , or advanced practice registered 23
nurse who is credentialed by the cabinet to perform vision testing under this 24
section. 25
(6) All driver vision testing forms completed under subsection (5) of this section shall: 26
(a) Attest that the applicant meets or exceeds the visual acuity standard and visual 27
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field standard established by the cabinet; 1
(b) Only be valid if the vision specialist or the credentialed osteopath, 2
credentialed physician, credentialed physician assistant, or credentialed 3
advanced practice registered nurse signed and completed the vision testing 4
form less than twelve (12) months prior to the date of application or renewal; 5
(c) State whether the driving privileges of the applicant shall be restricted to 6
mandate the use of corrective lenses; and 7
(d) Clearly indicate that the vision testing under this section is a screening for 8
minimum vision standards established in this section and is not a complete 9
eye examination. 10
(7) Any person seeking application or permi t under subsection (1) of this section shall 11
attest that he or she has submitted to and passed the visual acuity and visual field 12
tests required under this section. 13
(8) Any person renewing an operator's license under KRS 186.416 shall be exempt 14
from the vision testing requirements outlined in this section. 15
(9) Persons who meet the requirements of KRS 186.578 and are issued operator's 16
licenses under KRS 186.579 shall: 17
(a) Have their driving privileges restricted to the use of a bioptic telescopic 18
device; and 19
(b) Be exempt from this section. 20
(10) The Transportation Cabinet shall promulgate administrative regulations pursuant to 21
KRS Chapter 13A to implement the provisions of this section, including but not 22
limited to establishing visual field standards, the creation of a driver vision testing 23
form, and establishing a credentialing process for osteopaths, physicians, physician 24
assistants, and advanced practice registered nurses to conduct vision testing under 25
this section. 26
(11) The Transportation Cabinet may promulgate administrative regulations pursuant to 27
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KRS Chapter 13A to: 1
(a) Implement a system for electronic transmission of driver vision testing forms 2
and accompanying documentation; and 3
(b) Assess a fee to an applicant to cover the administrative costs of performing 4
on-site vision testing. Any funds received from this fee shall be deposited into 5
the photo license account established in KRS 174.056. 6
Section 8. The following KRS section is repealed: 7
311.860 Services performed in location separate from supervising physician -- 8
Nonseparate location -- Definition and exceptions. 9