2025 Texas Medical Board rules update

The Texas Medical Board (TMB) recently updated several rules that may affect how physicians may delegate tasks, document patient care, administer office-based anesthesia, and much more. In this podcast, Tanya Babitch and Robin Desrocher of TMLT's Risk Management Department help bring definition and insight to these new changes. Running time: 21 minutes
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Transcript:

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Tony Passalacqua:
Hello and welcome to this edition of TMLT's podcast, TrendsMD. I'm your host, Tony Passalacqua, and today I will be speaking with Tanya Babitch and Robin Desrocher of TMLT. Tanya Babitch is the Assistant Vice President of the Risk Management Department and Robin Desrocher is the Director of the Risk Management Department. Tanya and Robin are both longtime team members at TMLT and have helped our policyholders in a variety of ways to avoid claims of medical liability. Risk management services provided by TMLT for their policyholders include phone and email consultations; practice reviews; CME seminars; and a dedicated website of TMLT’s CME courses and offerings.

Today’s topic is the 2025 Texas Medical Board rules update.

Thank you, Tanya and Robin, for joining us today! So, I was wondering if you could share a little bit about yourselves with our audience. How long have you been with TMLT?  And maybe a bit about your background?

Tanya Babitch:
Thank you, Tony! This is Tanya. My career began in the early 90s working in Health Information Management and CME development for a medical center. In 2002, I joined TMLT’s Risk Management Department and have never looked back! I feel very lucky to work with an incredible team.

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Robin Desrocher:
Hello everyone, and I’m Robin and I’m a registered nurse with over 35 years of experience in the health care industry. My clinical background includes years at the bedside in cardiology, cardiothoracic surgery, and critical care. I later transitioned into ambulatory care, working across multiple specialties, before moving into health care administration. In 2006, I joined the Risk Management team at TMLT, and I’m proud to have celebrated my 19^th year with the organization and our talented team this past June.   

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Tony Passalacqua:
‍Congratulations on your 19^th year with the organization.

Robin Desrocher:
Thank you.

Tony Passalacqua:
‍The Texas Medical Board adopted rule changes to Part 9 of the Administrative Code. These rules that govern the practice of medicine in Texas have been reorganized. Would you share how these changes have impact licensed physicians?

Robin Desrocher:
Sure! Although we’re now well into August, it’s important to note these changes took effect back on January 9^th of this year based on a requirement for the TMB to regularly review their rules. And in doing so, there was a reduction from roughly 40 chapters down to 25. The reorganization shifted rules to entirely new chapters. And physicians should begin by familiarizing themselves with the updated chapters that affect their day-to-day practices such as medical records, physician advertising, delegation, complementary and alternative medicine standards, pain management, office-based anesthesia, and telemedicine to name a few of them.

Tanya Babitch:
Yeah. As Robin mentioned, the overall trend was the reduction of rules. We actually thought this podcast might end up being a bit longer, but it’s surprising that they reduced the rules so much — and kind of confounding! But as we continued to investigate, we realized that much of the content of the deleted rules still exists in other areas of the law, mostly within the Occupations Code and the Health and Safety Code. And we’ll talk about some of that today.

One resource that may be helpful to physicians or practices who were familiar with the old rules is a “rule review reorganization matrix” that was developed by the TMB. When the TMB published their new rules, they faced really an overwhelming number of inquiries and a lot of confusion. In response, they published this matrix. You can find this on the Board Rules page. It compares the old rules to the new, specifying new location and chapters and if rules have been deleted.

Tony Passalacqua:
What has TMLT done to keep policyholders informed about the reorganization of the TMB rules?  How has TMLT kept policyholders informed about the reorganization of these rules?

Robin Desrocher:
The first thing we did to help our policyholders was publish a bulletin on our website in January notifying them about the updates. We then hosted a spring webinar with one of our consultant attorneys, who explained the reorganization of the Board rules and key changes affecting Texas physicians. The recorded version of this webinar is available as a CME course on our learning platform for anyone interested in hearing more on this topic.

Now, for those familiar with the structure of the rules prior to January, this reorganization created a fair amount of confusion. However, if you’ve never reviewed the rules before, you may not feel the impact as strongly.

Tony Passalacqua:
Have the changes affected the risk management team at TMLT?

Robin Desrocher:
They sure have! We were very familiar with the previous structure and knew exactly where to find answers to common risk management questions that were related to the TMB requirements. Now, it’s taking time to become just as confident navigating the reorganized rules so we can continue to support our policyholders effectively. We sorted through all of our resources that cited TMB rules and revised them to reflect the updated rules.  And this took some time.

Tony Passalacqua:
Did the TMB eliminate entire rules, or did they just introduce new ones?

Robin Desrocher:
There are some instances where rules were removed from the Administrative Code. For example, Chapter 169 on the Authority of Physicians to Supply Drugs has been removed. However, much of the old content remains in the Texas Occupations Code within Chapter 158 titled Authority of Physicians to Provide Certain Drugs and Supplies, and within Section 157.002 on General Delegation of Administration and Provision of Dangerous Drugs.

Chapter 170 on Prescribing Controlled Substances was also repealed. Some of the prior requirements for this chapter are in the Texas Health and Safety Code sections that outline prescribing of Schedule II drugs, exceptions to electronic prescribing of controlled substances, opioid prescription limits, and Prescription Monitoring Program checks and there are some exceptions to the query requirements. Chapter 193 on Standing Delegation Orders has been repealed as well. Delegation is now covered in Chapter 169. It does appear that rules may have been eliminated from the Administrative Code to avoid overlap, simplify, or shorten language, and make the rules easier to understand. Though, as with any reorganization, there is an adjustment period. And we’re feeling that here in Risk Management.

Tony Passalacqua:
You just mentioned delegation. Would you elaborate on rules as they stand now for delegation and supervision?

Robin Desrocher:
Certainly. The TMB has consolidated all rules relating to delegation under what is now Chapter 169 of the Texas Administrative Code. Chapter 183 also addresses Physician Assistants and physician supervision of these practitioners. Outside of the TMB rules, the Texas Occupations Code also includes detailed delegation requirements in Chapter 157 on Authority to Delegate Certain Medical Acts.

Under the updated TMB rules, delegation must be through written protocols or prescriptive authority agreements depending on the type of delegate and the medical acts being assigned.

For example, when using standing delegation orders, standing medical orders, and protocols, several key elements must be met. A few of the requirements are:

• development and approval by the delegating physician;
• specific instructions for procedures;
• clearly outlining supervision levels;
• including a plan for addressing patient emergencies; and
• an annual review signed by the delegating physician.

Tony Passalacqua:
Thank you, Robin. It sounds like, in general, delegation requirements have remained as detailed, but the bulk of the requirements are located in the Texas Occupations Code (as opposed to the Texas Medical Board rules). Physicians should review both areas of the law. Moving on to another topic, have the rules regarding pain management changed?

Tanya Babitch:
This is a good question. There actually was significant confusion about this topic when the new rules went live. The Board rules on this topic moved to a totally new chapter and have actually made it much less detailed. The TMB rules regarding requirements for electronic prescribing of controlled substances, as Robin mentioned, and checking the PMP, or prescription monitoring program, have been repealed. BUT they are still in force in other areas of the Texas code! Like I said - as Robin mentioned.

Now, the Board references pain management rules under Chapter 172, so that’s where all of you out there listening should look. And it may actually be a bit confusing, because the chapter is labeled “Pain Management Clinics.”  This caused a lot of concern about whether these rules still apply to physicians practicing outside of a pain management clinic setting. And the Board has confirmed that these rules do, indeed, also apply to any physician- family medicine, surgeons, and not just those practicing in pain management clinics.

Specifically, the Board confirmed that rule §172.4, or Minimum Operational Standards for the Treatment of Pain Patients, applies to everybody prescribing. This rule includes requirements for treatment of pain patients, including ongoing evaluation and assessment of treatment, PMP checks, pain contracts, and more. So, physicians treating pain, in any specialty, should review these rules and be familiar with them.

And again, there are other laws that apply in the Occupations Code and Health and Safety Code, particularly the Controlled Substances Act. Some specific references include the Texas Occupations Code Chapter 158. Authority of Physician to Provide Certain Drugs and Supplies  and Sec. 157.002, which I believe Robin mentioned regarding General Delegation of Administration and Provision of Dangerous Drugs.

So, those are the places that you can go to look for applicable pain management rules.

Tony Passalacqua:
It seems that there has been a lot of focus on medical spas and IV hydration clinics. Have the TMB rules in this area changed?

Robin Desrocher:
Yes, they certainly have. Under the new rules, specifically Chapter 169, Subchapter E, there are clearer transparency requirements for medical spas and IV therapy clinics. The rules now require:

• posting the delegating physician’s name and Texas medical license number in all public areas and treatment rooms;
• having all staff wear identification that clearly displays their name and credentials; and
• ensuring all advertising materials must include the supervising physician’s name, unless of course the location is the physician’s primary site of practice.

These updates are intended to enhance patient awareness and promote accountability in settings where physicians are delegating these acts to providers other than advanced practice providers, such as RNs or other staff.

Another notable change to the new rule is that a physician, physician assistant, OR advanced practice registered nurse may now serve as the individual available for emergency consultation in the event of an adverse outcome. That said, the delegating physician must still be available to provide emergency consultation as needed.

In addition, a physician must be trained in, familiar with, and capable of performing any medical act they delegate – ensuring the act is carried out in accordance with the standard of care. Standard of care is key here.

Tanya Babitch:
Yeah. Any physician who is delegating these types of “nonsurgical cosmetic” acts, colonic irrigation, or IV therapy should review the rules in full. In addition to what Robin mentioned, the rule includes requirements regarding the delegating physician ensuring the training and competency of staff, protocols, specific requirements for written orders, and requirements for establishing a relationship with the physician (or advanced practice provider) prior to treatment by other staff.

I’d also like to mention a related topic here. In the 2025 session, the Texas legislature passed a law that addresses elective IV therapy. Specifically, those “wellness” or “hangover hydration” type services that occur outside of a physician’s office or a health care facility.

The administration of these services may not be delegated to everyone. The new law, HB 3749, or “Jenifer’s Law,” states that a physician may delegate ordering of elective IV therapy to a PA or APRN who is “adequately supervised,” with a prescriptive authority agreement (PAA). The only persons that a physician may delegate administration of elective IV therapy to are a PA, APRN, or RN under adequate physician supervision. So, other staff, such as MAs or LVNS or other non-medical personnel, may not administer elective IV therapy in these settings.

Tony Passalacqua:
Has the TMB made any additional comments about delegation rules in these Medspa or “wellness” settings?‍

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Robin Desrocher:
Yes, actually, Dr. Zaafran, the president of the Texas Medical Board, addressed this issue in their February 2025 bulletin. He said, “These acts are considered medical procedures or treatments and therefore must be administered by a Texas licensed physician or properly delegated to qualified nonphysicians to provide such services while under the physician’s delegation and supervision.”

Tanya Babitch:
Yeah. The TMB is looking very closely — and has for several years — but is looking very closely at medspas and IV therapy clinics. There was a high-profile death that happened in a “wellness” clinic where elective IV therapy was administered by a person with really no medical training. This prompted the law that I just mentioned earlier- “Jenifer’s Law,” and has prompted increased scrutiny from the Board.

Tony Passalacqua:
Are there any other significant rule changes that you have noted?

Tanya Babitch:
One area that we encourage physicians to review are the rules regarding “Office Based Anesthesia.” These rules are now under Chapter 173. So, totally new chapter. The TMB made changes to some of the anesthesia “level” definitions that may affect practices that offer anesthesia. You know, whether that’s nitrous oxide, minimal sedation, or higher levels of anesthesia and sedation. Whether you administer the anesthesia, or you are bringing in an external anesthesia provider, the TMB has made it clear that these rules apply to you. So, we strongly encourage you to review the new definitions and know what your “level” is, as defined by the TMB.

Even “Level 1”, which includes minimal sedation by narcotic analgesics or anxiolytics by mouth or delivery of nitrous oxide/oxygen inhalation sedation, has requirements regarding personnel and equipment. For many practices, the new definitions may not change anything. You may remain at the same level, but we recommend you check. If you are anything higher than Level 1, there are a number of additional requirements — pre-anesthesia assessment, monitoring, and other rules — that are going to apply to you. In addition, you may need to register as an office-based anesthesia provider with the TMB. So, strongly recommend that any physicians offering any type of anesthesia in their practice review these rules, even if it’s minimal. Even if you are just doing local, take a look. Know what these levels are. Again, these are in Chapter 173.

We have also seen changes in several areas that are small, but still worth mentioning to physicians.

The chapter on Medical Records, which is now Chapter 163, so that’s moved as well, is much shorter, but retains the overall Board intent to require adequate medical record documentation. That’s the bottom line. One new item in this chapter is the addition of specific mention of Prescription Monitoring Program checks. The rule now states that an “adequate” medical record must include documentation of a review of the patient's PMP history. So, you don’t just have to do it, you have to document in the record that you did it and that you actually reviewed the information. These checks are required before prescribing opioids, benzodiazepines, barbiturates, and carisoprodol. The TMB is really making it clear they want you to document your review of the PMP data in the patient’s record.

Robin Desrocher:
That was a lot of information on medical records there. There is also a small change that applies to physicians who are closing or leaving a practice. In that same Chapter, under Rule §163.4, Physician Responsibilities when Leaving a Practice, the old rules used to allow a physician leaving a practice the option of putting a notice in the local newspaper OR their website. Well, now the newspaper is no longer mentioned as an option in that rule.

Tanya Babitch:
There is an additional change that affects practices when a physician is leaving a group, also in that same chapter. The rule still states that physicians must notify patients who have been seen within the last two years, but it now specifies that groups must provide the leaving physician with a list of those patients to allow for appropriate notification. So, if you are leaving or closing a practice, we would recommend that you closely review the updated Board rule 163.4, as some of that wording has changed a bit.

Robin Desrocher:
And Tanya, another area where we have seen significant changes, is in the Board rule addressing Complementary and Alternative Medicine. This topic is now covered in Chapter 171 and is significantly streamlined.

Tanya Babitch:
Yeah. Although these rules are actually much shorter now, we do think it’s worth pointing out that this chapter exists. In our discussions with physicians, we find that many are really not aware of this rule at all. So, it is important to understand what the TMB considers “complementary” or “alternative.” The rule defines these terms. Take a look at it. “Alternative medicine” is defined by the board as methods of diagnosis, treatment, or interventions that are not generally considered as conventional treatment or medicine and may or may not be regulated by the FDA. And “complementary medicine” is defined as the use of a combination of conventional medicine and some form of alternative medicine.

Robin Desrocher:
So, for our listeners, if you are doing anything that could be considered “complementary” or “alternative” medicine in any form, review Chapter 171. There is now a requirement that you use a specific consent form, and this is new. The Board has developed a standardized 3-page disclosure and consent form that must be used by practices offering these services. You should not change the wording of this form unless of course you are translating the information into another language. You may add additional pages with supplemental information, as necessary. But the rules state that the fully executed form should be retained in the patient’s record. The form is accessible on the TMB website; if you go directly to the Board Rule 171.2, there is a link to this form.

Tony Passalacqua:
Well, that’s a lot of information with all of the new changes that have occurred in 2025. Do you have any last words of wisdom about the rule changes, or anything you want to share with physicians?

Tanya Babitch:
Yeah. Honestly, I think it’s important that physicians not assume that just because something is no longer in the board rules, that it is no longer a law. That could be very dangerous! As we discussed throughout our conversation today, many of the previous rules actually still live on in other areas of Texas law. And if you are a TMLT policyholder and have questions about a specific rule, you can reach out to our Risk Management team for help. We may be able to assist you in locating either the new TMB rule, or another part of the law that addresses your question. If you’re not insured with us, your own malpractice liability carrier may be able to help. And, if all else fails, you can always try reaching out to the TMB’s customer service department.

Robin Desrocher:
And we did certainly talk about and reference so many rules and regulations during this podcast. So, we’d like to point out that there is a transcript available where you’ll find all the relevant citations if you want to research or dig into the rules further. And if you have questions about the Board’s motivation or the specifics of the current rules, we do encourage you to contact the Board directly and get involved.

And we do have one last recommendation for you: if you are not already signed up to receive the Texas Medical Board’s Bulletins, we highly recommend that you do so. This will keep you updated and informed on any changes, rule proposals, and areas of focus for the Board. Just go to the TMB’s main website page, and on the lower left side of the screen, there’s a field that allows you to join their email list.

Thank you so much for listening!

Tanya Babitch:
Yeah. Thank you!

Tony Passalacqua:
Thank you for listening to our podcast. If you are a policyholder, please feel free to contact us with any questions by calling 1-800-580-8658, or check out our resources by visiting us at www.tmlt.org.  

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