Scope of Practice

North Carolina Medical Assistants in Inpatient Settings

I recently received the following question from a manager at a health care system in North Carolina: 

We are looking at ways to assist nurses in the hospital setting due to the nursing shortage. Can medical assistants practice in a hospital setting without a nursing assistant certification? 

Medical assistants are permitted to meet the requirements and register with the state as certified nursing assistants (CNAs) and medication aides. Short of this, medical assistants are considered unlicensed assistive personnel (UAP) when working under nurse supervision in inpatient settings. 

The North Carolina Board of Nursing has issued some detailed and helpful position statements on what nurses are permitted to delegate to UAP. See the following documents for additional details: 

Scope of Practice

The AAMA Achieves Legislative Victories in Maryland and Washington

During the COVID-19 pandemic, medical assistants have risen to the occasion by undertaking expanded duties. As a result, they have been given opportunities to join in combatting the pandemic because of favorable federal and state legislation, executive orders, and official rules and interpretations by federal agencies. These developments have been chronicled on the “State Scope of Practice Laws” webpage of the AAMA website, via this blog, and in CMA Today

Notably, two such bills from Maryland and Washington will have precedential weight and influence on future medical assisting laws and create a lasting impact extending well beyond the pandemic. 

To learn more about these momentous bills and related trends in medical assisting, read the July/August 2021 Public Affairs article in CMA Today, “The AAMA Achieves Legislative Victories in Maryland and Washington.” 

Scope of Practice

Multi-State Scope of Practice for Medical Assistants

I recently received an inquiry regarding medical assisting scope of practice laws across the U.S.:

I am a CMA (AAMA) residing in Washington. I am trying to find all the scope of practice laws for my current job. I work for a start-up health care/technology company [that] serves all 50 states. All our physicians are licensed in each state, and we are trying to implement the use of CMAs (AAMA) to better serve our patient load. Would I need to follow each state’s rules, or because the company is in Washington, would I just follow Washington’s rules?

I feel as though Washington [law] is the strictest. [Do you think] any other states seem to be a little stricter?

To find the medical assisting laws of all states, go to the “State Scope of Practice Laws” webpage on the AAMA website

Because medical assistants employed by this company work under the authority of physicians in all states, they are required to abide by the laws of all states.

Washington has more requirements that medical assistants must meet to work as medical assistants than any other state. Further, Washington law requires medical assistants to meet specified requirements for a category of medical assistants and register with the Washington State Department of Health in that category in order to work.

However, some states have more limitations on tasks that medical assistants are permitted to be delegated and to perform.

Two of my Public Affairs articles published in CMA Today, “What Tasks Are Delegable to—and Performable by—Medical Assistants?” part I and part II, contain legal principles generally applicable in all U.S. jurisdictions. Note the following excerpt from the handout that served as the source material for those articles:

7. General legal principles—

• It is not permissible for medical assistants to perform tasks that constitute the practice of medicine, or require the skill and knowledge of physicians or other licensed providers;

• It is not permissible for medical assistants to perform tasks that are restricted in state law to other health professionals—often licensed health professionals;

• It is not permissible for medical assistants to perform tasks that require the exercise of independent clinical judgment, and/or the making of clinical assessments, evaluations, or interpretations;

medication reconciliation, Scope of Practice

Medication Reconciliation Post-Discharge Measure Victory

The ability of appropriately educated and professionally credentialed medical assistants to perform—under the authority of licensed providers—medication reconciliation post-discharge has become widely recognized by providers. However, the fact that medical assistants are not explicitly mentioned in the National Committee for Quality Assurance (NCQA) post-discharge medication reconciliation measure had given rise to some uncertainty about whether medication reconciliation by medical assistants would count toward determining whether the following measure has been met:

Quality ID #46 (NQF 0097): Medication Reconciliation Post-Discharge

NUMERATOR (SUBMISSION CRITERIA 1 & 2 & 3):

Medication reconciliation conducted by a prescribing practitioner, clinical pharmacist or registered nurse on or within 30 days of discharge

I asked the NCQA whether medication reconciliation by medical assistants would count toward meeting the above quality measure. An excerpt and further details about this letter are available in my November 2020 Legal Eye post. The NCQA provided the following answer:

NCQA recognizes the supervising physician as providing the service when they have signed off on the medical record/documentation. It is our understanding many licensed practical nurses (LPNs) and medical assistants work with physicians and registered nurses (RNs). With this in mind, medication reconciliation provided by the medical assistant and signed off by a physician, [nurse practitioner, physician assistant, or clinical pharmacist with prescribing privileges], or RN may be counted toward NCQA Medication Reconciliation indicators as the signature indicates additional clinical oversight for this work.

Additional updates from the NCQA will be reported in future Legal Eye blog posts.

delegation, Scope of Practice

Permissible Delegation to Montana Medical Assistants

I recently received the following appeal from a licensed practical nurse working in Montana:

I’m requesting something in writing that states that CMAs (AAMA) can still administer immunizations. The verbiage that my bosses are reading has [caused them to change] what our medical assistants can and can’t do. I depend on [medical assistants] being able to give shots (i.e., immunizations) when working with me.

For documentation related to this issue, go to the State Scope of Practice Laws webpage on the AAMA website to find the medical assisting laws of all states, including Montana.

Note the following from the Montana Code Annotated (MCA):

37-3-104. Medical assistants — guidelines. (1) The board shall adopt guidelines by administrative rule for:

(a) the performance of administrative and clinical tasks by a medical assistant that are allowed to be delegated by a physician, physician assistant, or podiatrist, including the administration of medications; and

(b) the level of physician, physician assistant, or podiatrist supervision required for a medical assistant when performing specified administrative and clinical tasks delegated by a physician, physician assistant, or podiatrist. However, the board shall adopt a rule requiring onsite supervision of a medical assistant by a physician, physician assistant, or podiatrist for invasive procedures, administration of medication, or allergy testing. [Italics added.]

Further, note the following from the Administrative Rules of Montana (ARM):

24.156.401    MEDICAL ASSISTANT – DELEGATION AND SUPERVISION

(1) A health care provider authorized by 37-3-104, MCA, may delegate administrative and clinical tasks which are within the delegating health care provider’s scope of practice to medical assistants who:

(a) work in the delegating health care provider’s office under the general supervision of the delegating health care provider; and

(3) A health care provider delegating administrative and/or clinical tasks to a medical assistant shall:

(c) personally provide onsite direct supervision as defined by ARM 24.156.501 to a medical assistant to whom the health care provider has delegated:

(i) injections other than immunizations;

(ii) invasive procedures;

(iii) conscious sedation monitoring;

(iv) allergy testing;

(v) intravenous administration of blood products; or

(vi) intravenous administration of medication [Italics added.]

The definition for direct supervision is in ARM “Definitions”:

(7) “Direct supervision” means the supervising physician is:

(a) physically present in the same building as the person under supervision; or

(b) in sufficiently close proximity to the person under supervision to be quickly available to the person under supervision. [Italics added.]

Given this language from the Montana statutes and regulations, my legal opinion is that Montana law permits physicians to delegate to medical assistants—who have the knowledge and competence outlined in the Montana rules—the administration of immunizations under the physician’s general supervision. My opinion is also that Montana law requires the delegating physician to be exercising direct supervision when medical assistants are performing the following tasks outlined in ARM:

(ii) invasive procedures;

(iii) conscious sedation monitoring;

(iv) allergy testing;

(v) intravenous administration of blood products; or

(vi) intravenous administration of medication