Permissible Supervision Duties for North Carolina Medical Assistants

I recently received the following question:

[In North Carolina,] can a CMA (AAMA) be a supervisor over LPNs [licensed practical nurses] and RNs [registered nurses], as well as CMAs (AAMA)?

 To answer this question, note the following information from the “Frequently Asked Questions” webpage on the North Carolina Board of Nursing website:

Can a nurse be supervised by an unlicensed person or another discipline?

A non-nurse (other than a licensed physician) may not supervise nursing practice but could supervise basic employment issues (i.e., administrative supervision, human resource issues [such as] time, attendance, [and] dress code).

Supervision Requirements for Incident-To Billing

I recently received the following question about incident-to billing: 

My compliance officer asked me to reach out to … seek direction on where we could find current information about [whether] it is permitted to bill incident to when a medical assistant is supervised and billed under a PA [physician assistant] as the supervising physician.

We read your 2016 article … about [Medicare’s Chronic Care Management] and [Transitional Care Management] billing. Oregon recently passed laws where PAs enter into a collaborative agreement with providers. [Does this change whether the Centers for Medicare & Medicaid Services] will now allow incident-to billing with PAs supervising [medical assistants]?

In the Medicare Benefit Policy Manual, the definition of physician includes physician assistants and nurse practitioners. As demonstrated in the 2016 Public Affairs article, medical assistants are classified as auxiliary personnel and clinical staff under Medicare law.

Therefore, medical assistants’ services performed incident to those of a PA may be billed incident to the services of the PA in the same way that they may be billed incident to the services of an MD or DO.

Vaccine Administration under Utah Medical Assisting Law

On March 10, 2022, the Utah legislature amended Section 58-67-102 of the Utah statutes to permit medical assistants to administer vaccines under general physician supervision rather than indirect supervision. Note the following definitions from the Utah Administrative Code:

(b) “Indirect supervision” means the supervising licensee:

 (i) has given either written or verbal instructions to the person being supervised;

 (ii) is present within the facility in which the person being supervised is providing services; and

 (iii) is available to provide immediate face-to-face communication with the person being supervised as necessary.

(c) “General supervision” means that the supervising licensee:

(i) has authorized the work to be performed by the person being supervised;

(ii) is available for consultation with the person being supervised by personal face-to-face contact, or direct voice contact by telephone, radio or some other means, without regard to whether the supervising licensee is located on the same premises as the person being supervised; and

(iii) can provide any necessary consultation within a reasonable period of time and personal contact is routine.

New Mexico Supervision Requirements for Medical Assistants

I recently received a question from a health officer in New Mexico who wanted to know whether a nurse practitioner can supervise a medical assistant without a physician on-site.

The “State Scope of Practice Laws” webpage on the AAMA website provides information on medical assisting–related laws of 49 states, including New Mexico. The second document in the “New Mexico” section, an excerpt from New Mexico Board of Nursing regulations, classifies medical assistants as unlicensed professionals under the New Mexico nursing law.

My legal opinion is that New Mexico nursing law permits advanced practice registered nurses, including nurse practitioners, to delegate to unlicensed professionals—such as medical assistants working under their supervision—tasks that do not require the exercise of independent clinical judgment or the making of clinical assessments or evaluations. Note the following language from the regulations of the New Mexico Board of Nursing: 

B. The nurse shall assign/delegate to licensed and unlicensed persons only those nursing actions which that person is prepared, qualified or licensed or certified to perform.

(1) The nurse is accountable for assessing the situation and is responsible for the decision to delegate or make the assignment.

(2) The delegating nurse is accountable for each activity delegated, for supervising the delegated function or activity, and for assessing the outcome of the delegated function or activity. 

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