delegation, Scope of Practice

The Relationship between Scope and Competence

Medical assistants are under a legal duty to not exceed the legal scope of practice in their state.  Medical assistants are also under a legal duty to perform all tasks competently.  It is important to understand the relationship between these two legal duties.

Even if a medical assistant performs a task competently, and meets or exceeds the standard of care that is required of a medical assistant, the medical assistant could face legal sanctions if the task is beyond the legal scope of practice for medical assistants in the state.

Similarly, if a medical assistant performs a task that is permitted under state law, the medical assistant (and, most likely, the medical assistant’s delegating provider) could be sued for negligence if the task is not performed competently.

Medical assistants must make sure they perform all tasks competently.  They must also make sure that the tasks they perform do not exceed the legal scope of practice in the state (or other American jurisdiction) in which they are working. Of course, the best way to do so is by remaining informed about the laws in your own state. To help health care professionals navigate this issue, the AAMA website has a large collection of documents relating to different states’ scope of practice laws. Any medical assisting scope of practice questions that are not covered by these materials can be emailed to me at dbalasa@aama-ntl.org.

Certification and the CMA (AAMA) Credential, On the Job, Professional Identity

The CMA (AAMA) Credential in Conjunction with Other Roles

In recent days I received the following two questions:

I would like to know if it is legal in the state of Michigan to work as a medical assistant and a nursing assistant. I started as a certified nursing assistant (CNA) and later went to school and became a CMA (AAMA). Can I work for two companies—for one company as a medical assistant and for another company as a nursing assistant? I have tried to search for an answer elsewhere but have had no luck.

I am currently in nursing school (practical nursing). I will graduate in May. Am I able to maintain my CMA (AAMA) even after I obtain my licensed practical nurse (LPN) license? I hope I am able to do so.

I responded to these questions as follows:

  1. Thank you for your question. It is my legal opinion that Michigan law permits an individual to work as a nursing assistant for one employer, and as a medical assistant for another employer. It is important that you keep your CMA (AAMA) current, and that you fulfill any requirements for maintaining your CNA.
  1. Thank you for your question. There is no law or policy that would forbid you from keeping your CMA (AAMA) credential after you become an LPN. As you know, you will have to recertify every sixty (60) months in order to maintain currency of your CMA (AAMA).
On the Job, Professional Identity, Scope of Practice

Ohio Passes Senate Bill 110

I am happy to report that the Ohio Legislature has passed Senate Bill (SB) 110, which has now been signed into law by Governor John Kasich. The bill becomes effective 90 days after signing.

This bill gives nurse practitioners (NPs) and physician assistants (PAs) the ability to delegate medication administration to unlicensed allied health professionals, such as medical assistants working under their supervision in outpatient settings.

See the following relevant passages from SB 110, the first from page 20 of the attached, which is the version that has passed both Houses of the Ohio legislature:

Sec. 4723.48. (A) A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner seeking authority to prescribe drugs and therapeutic devices shall file with the board of nursing a written application for a certificate to prescribe. The board of nursing shall issue a certificate to prescribe to each applicant who meets the requirements specified in section 4723.482 or 4723.485 of the Revised Code. …

(C)(1) The holder of a certificate issued under this section may delegate to a person not otherwise authorized to administer drugs the authority to administer to a specified patient a drug, other than a controlled substance, listed in the formulary established in rules adopted under section 4723.50 of the Revised Code. The delegation shall be in accordance with division (C)(2) of this section and standards and procedures established in rules adopted under division (Q) of section 4723.07 of the Revised Code.

(2) Prior to delegating the authority, the certificate holder shall do both of the following:

(a) Assess the patient and determine that the drug is appropriate for the patient;

(b) Determine that the person to whom the authority will be delegated has met the conditions specified in division (D) of section 4723.489 of the Revised Code.

Note also the following on pages 22 and 23:

Sec. 4723.489. A person not otherwise authorized to administer drugs may administer a drug to a specified patient if all of the following conditions are met:

(A) The authority to administer the drug is delegated to the person by an advanced practice registered nurse who is a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner and holds a certificate to prescribe issued under section 4723.48 of the Revised Code.

(B) The drug is listed in the formulary established in rules adopted under section 4723.50 of the Revised Code but is not a controlled substance and is not to be administered intravenously.

(C) The drug is to be administered at a location other than a hospital inpatient care unit, as defined in section 3727.50 of the Revised Code; a hospital emergency department or a freestanding emergency department; or an ambulatory surgical facility, as defined in section 3702.30 of the Revised Code.

(D) The person has successfully completed education based on a recognized body of knowledge concerning drug administration and demonstrates to the person’s employer the knowledge, skills, and ability to administer the drug safely.

(E) The person’s employer has given the advanced practice registered nurse access to documentation, in written or electronic form, showing that the person has met the conditions specified in division (D) of this section.Sub. S. B. No. 110 131st G.A. 23

(F) The advanced practice registered nurse is physically present at the location where the drug is administered.

Note the following from pages 36 and 37:

Sec. 4730.203. (A) Acting pursuant to a supervision agreement, a physician assistant may Sub. S. B. No. 110 131st G.A. 37

delegate performance of a task to implement a patient’s plan of care or, if the conditions in division (C) of this section are met, may delegate administration of a drug. Subject to division (D) of section 4730.03 of the Revised Code, delegation may be to any person. The physician assistant must be physically present at the location where the task is performed or the drug administered.

(B) Prior to delegating a task or administration of a drug, a physician assistant shall determine that the task or drug is appropriate for the patient and the person to whom the delegation is to be made may safely perform the task or administer the drug.

(C) A physician assistant may delegate administration of a drug only if all of the following conditions are met:

(1) The physician assistant has been granted physician-delegated prescriptive authority.

(2) The drug is included in the formulary established under division (A) of section 4730.39 of the Revised Code.

(3) The drug is not a controlled substance.

(4) The drug will not be administered intravenously.

(5) The drug will not be administered in a hospital inpatient care unit, as defined in section 3727.50 of the Revised Code; a hospital emergency department; a freestanding emergency department; or an ambulatory surgical facility licensed under section 3702.30 of the Revised Code.

(D) A person not otherwise authorized to administer a drug or perform a specific task may do so in accordance with a physician assistant’s delegation under this section.

Scope of Practice

Q and A: Medical Assistants and CPOE, Part 2 (Post 5 of 5)

Because most CMAs (AAMA) work under the direct supervision of “eligible professionals” (as defined in the rules of the Centers for Medicare and Medicaid Services [CMS]), this post focuses on some common questions surrounding the provisions of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Program that are applicable to eligible professionals, not those provisions that are applicable to “eligible hospitals” and “critical access hospitals.”

Q: Do medical assistants have to be credentialed to enter medication, laboratory, and radiology orders into the EHR if such entry is not being counted toward meeting the measure for the Core Objective “CPOE for Medication, Laboratory, and Radiology Orders”?

A: No. There is no other CMS regulation, federal law, or state law that requires medical assistants to be credentialed as a prerequisite for entering orders into the Electronic Health Record if such entry is not being counted toward meeting the Stage 1 and Stage 2 percentage requirements for entering orders into the CPOE. In other words, the absolute legal requirement is that medical assistants be credentialed (as defined in the CMS final rule) when entering orders for calculating compliance with the “CPOE for Medication, Laboratory, and Radiology Orders” Core Objective.

Q (part 1 of 2): When does the CMS final rule allowing credentialed medical assistants to enter orders into the CPOE go into effect?

Q (part 2 of 2): Does the CMS final rule only apply to entry of orders under Stage 2 of the Incentive Program?
Note the following answer to CMS FAQ 7693:

We [CMS] have revised the description of who can enter orders into the EHR and have it count as CPOE and have it count for purposes of the CPOE measure. This revision is available for EHR reporting periods in 2013 and beyond regardless of what stage of meaningful use the provider is attesting to. [Emphasis added.]

A (part 1 of 2): The CMS rule allowing credentialed medical assistants to enter medication, laboratory, and radiology orders into the computerized provider order entry (CPOE) system is in effect for reporting periods in 2013. It is not correct to assert that the CMS rule does not go into effect until 2014.

A (part 2 of 2): The above CMS FAQ clearly states that the rule allowing credentialed medical assistants to enter orders into the CPOE applies to all stages of the Medicare and Medicaid Incentive Program. Thus, it applies to Stage 1 as well as Stage 2, and will apply to Stage 3 when it goes into effect.

Accreditation, Certification and the CMA (AAMA) Credential, Scope of Practice

Q and A: Medical Assistants and CPOE, Part 1 (Post 4 of 5)

Because most CMAs (AAMA) work under the direct supervision of “eligible professionals” (as defined in the rules of the Centers for Medicare and Medicaid Services [CMS]), this post focuses on some common questions surrounding the provisions of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Program that are applicable to eligible professionals, not those provisions that are applicable to “eligible hospitals” and “critical access hospitals.”

Q: Who can enter orders into the EHR to contribute to the meeting of the Stage 1 and 2 measures for CPOE?

A: Stage 1 of the Incentive Program specified that only “licensed health care professionals” could enter orders into the CPOE system for meaningful use calculation purposes. At the urging of the American Association of Medical Assistants and other parties, on August 23, 2012, CMS issued a final rule allowing “credentialed medical assistants” to enter orders into the CPOE system for the purpose of calculating compliance with this Core Objective. The CMS Stage 2 Eligible Professional Meaningful Use Core Measures document, issued in October of 2012, includes the following statement: “Any licensed healthcare professionals and credentialed medical assistants can enter orders into the medical record for purposes of including the order in the numerator for the objective of CPOE…”

Q: How does CMS define “credentialed medical assistants”?

A: According to the 2012 CMS document cited immediately above, “Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant.”

Q: Does an associate degree, certificate, or diploma from an academic medical assisting program fall within the CMS definition of a credentialed medical assistant?

A: In my opinion, the context of the August 23, 2012 CMS final rule does not allow an associate degree, certificate, or diploma from a medical assisting program to be considered as a medical assisting credential. The medical assisting credential must be granted by a body that requires medical assistants to pass a standardized test.

Q: Would a “credential” based on experience and recommendations meet the CMS definition of a credentialed medical assistant?

A: No. The intent of CMS was that a medical assistant pass some sort of examination in order to fulfill the definition of a “credentialed medical assistant.”