1. Medical Assistants: Scope of
Practice, Education, and Credentialing
National Council of State Boards of Nursing
June 21, 2012
Donald A. Balasa, JD, MBA
Executive Director, Legal Counsel
American Association of Medical Assistants

2. • Medical assistants are allied health professionals
who work primarily in outpatient/ambulatory health
care delivery settings, most often under direct
physician supervision, and who are able to be
delegated both back-office clinical duties as well as
front-office administrative duties.
• Medical assistants are different from: (1) nursing
assistants; and (2) medication aides/assistants.

3. • Nursing assistants work primarily in inpatient settings, most
often under registered nurse (RN) supervision, and are
delegated bedside, clinical duties.
• Medication aides/assistants work primarily in inpatient
settings, and are able to pass medications to patients, usually
under RN supervision.
• In some states, medication aides/assistants must first be
certified nursing assistants (CNAs). In other states, individuals
can be medication aides/assistants without being CNAs.

4. • Because medical assistants are delegated duties by physicians,
in most jurisdictions medical assistants derive their legal
authority to practice from state medical practice acts and
regulations of the state boards of medical examiners.
• In most jurisdictions, medical assistants work under direct
physician supervision. “Direct supervision” is usually defined
as the delegating/supervising/overseeing physician(s) being
on the premises and reasonably available when the medical
assistants are undertaking clinical duties.
• From a precise legal standpoint, medical assistants are not
delegated nursing duties. They are delegated clinical and
administrative duties by physicians.

5. • Under the laws of most states, physicians are permitted
(explicitly or implicitly) to ask advanced practice registered
nurses (most frequently nurse practitioners), physician
assistants, and registered nurses to supervise medical
assistants in the performance of duties delegated to the
medical assistants by the physician(s).
• According to Working with Others: A Position Paper, National
Council of State Boards of Nursing:
– Accepting an assignment to supervise—There are situations when a nurse may be
assigned to supervise a staff member who has been delegated tasks by another licensed
provider (e.g., in a physician’s office). There are other situations where the authority to
provide tasks or procedures…has been granted by a statute or rule/regulation separate
from the Nurse Practice Act or rules/regulations… (page 15)

6. • An increasing number of jurisdictions are permitting advanced
practice registered nurses—especially nurse practitioners—to
practice independently and autonomously, sometimes in
outpatient settings.
• In such situations, the operative law for determining what
duties nurse practitioners are permitted to delegate to
unlicensed allied health professionals such as medical
assistants is the nurse practice act and the rules and opinions
of the state board of nursing.

7. • There are many varieties of medical assisting educational programs
throughout the United States.
• Some educational programs only teach the administrative aspects of
medical assisting, and other programs only teach the clinical aspects.
• Medical assisting courses are taught at both the secondary and
postsecondary levels.
• Medical assisting programs at the postsecondary level are taught in
community colleges and vocational/technical schools. Such
postsecondary academic programs are either: (1) one-year certificate or
diploma programs; or (2) two-year associate degree programs.

8. • There are two accrediting bodies that are recognized by the
United States Department of Education (USDE) or the Council
for Higher Education Accreditation (CHEA) as programmatic
accreditors of postsecondary medical assisting programs:
– The Commission on Accreditation of Allied Health Education Programs
(CAAHEP);
– The Accrediting Bureau of Health Education Schools (ABHES).
• Some postsecondary academic programs do not have
programmatic accreditation by either CAAHEP or ABHES.
Such programs are offered in schools that are institutionally
accredited.

9. • There are two types of academic accreditation:
– Institutional accreditation
– Programmatic, or specialized, accreditation
• Institutional accreditation is a process whereby a school as a
whole is evaluated by the accrediting body.
• Academic, or specialized, accreditation is a process whereby a
particular program or course of study within a school is
evaluated by the accrediting body.

10. • In the strictest sense, only two states require medical assistants to
have formal medical assisting education: South Dakota (for all
aspects of medical assisting) and New Jersey (just for injections).
– Medical assisting in South Dakota is under the joint jurisdiction
of the Board of Medical and Osteopathic Examiners and the
Board of Nursing:
• 36-9B-5 Registration by Board of Medical and Osteopathic
Examiners. The Board of Medical and Osteopathic Examiners
shall register a medical assistant following the submission of
an application by an applicant for registration who has
graduated from an accredited school or a school which
meets standards similar to an accredited school and has met
other qualifications established by the Board of Medical and
Osteopathic Examiners and the Board of Nursing.

11. • Under New Jersey law, only medical assistants who
have graduated from a medical assisting program
that meets the requirements of the New Jersey
Board of Medical Examiners are permitted to be
delegated by physicians certain types of injections.

12. • As is the case with medical assisting educational programs, there are many
different medical assisting credentials throughout the United States.
• There are medical assisting tests and credentials that are exclusively
administrative.
• There are medical assisting tests and credentials that are exclusively
clinical.
• There are medical assisting tests and credentials that measure both
administrative and clinical knowledge.

13. • In almost every states, medical assisting credentials are
voluntary national credentials, not mandatory state
credentials.
• However, increasing numbers of employers and malpractice
insurance carriers are preferring, or even insisting, that
medical assistants have a credential.
• This is due to the fact that employing credentialed medical
assistants is evidence that the employer is demonstrating due
diligence in hiring medical assistants who have shown a
degree of mastery of medical assisting knowledge by the
passing of a standardized national examination.

14. • There are four (4) medical assisting credentials that are
accredited by the National Commission for Certifying Agencies
(NCCA):
– The Certified Medical Assistant [CMA (AAMA)] of the Certifying Board
of the American Association of Medical Assistants (AAMA);
– The Registered Medical Assistant [RMA(AMT)] of American Medical
Technologists (AMT);
– The Certified Clinical Medical Assistant (CCMA) of the National
Healthcareer Association (NHA);
– The National Certified Medical Assistant (NCMA) of the National
Center for Competency Testing (NCCT).

15. • To be accredited by the NCCA, a certification program must
have a recertification requirement that requires certificants to
furnish proof of continuing knowledge in the field.
• To be NCCA accredited, a certification program must also have
a reporting mechanism that allows allegations of
incompetence or wrongdoing to be brought against the
certificants, and an investigation and disciplinary mechanism
that can result in revocation of the certification or other
measures if the certificant is found negligent or malfeasant.

16. • The CMA (AAMA) is the only certification program that
requires candidates to graduate from a medical assisting
education program. Graduation from a CAAHEP or ABHES
accredited postsecondary medical assisting program is a
prerequisite for taking the CMA (AAMA) Certification
Examination.
• The CMA (AAMA) is the only certification program that
requires proof of current certification in CPR as a requirement
for recertification.
• The CMA (AAMA) is the only certification program that utilizes
the National Board of Medical Examiners (NBME) as test
consultant.

17. • “It is unethical, illegal, and a disservice to the medical assisting
profession for medical assistants to refer to themselves as “nurses,”
“office nurses,” “doctors’ nurses,” or any other generic term that
even remotely implies that medical assistants are nurses.” “Medical
Assistants Must not Refer to Themselves as Nurses,” CMA
Today, Jan-Feb 2011, Donald A. Balasa.
• “Are medical assistants permitted to accept verbal orders from the
delegating physician? Medical assistants are permitted to receive
and execute orders from the overseeing, delegating, or supervising
physician(s) as long as such orders do not require the medical
assistant to exercise independent professional judgment in the
execution of the orders, or to make clinical assessments or
evaluations.” “Frequent Questions about Medical Assistants’ Scope
of Practice,” CMA Today, March-April 2012, Donald A. Balasa.

18. • “Are physicians allowed to delegate patient education to
medical assistants? Physicians are allowed to delegate
patient education to competent and knowledgeable medical
assistants as long as the content of such education has been
approved by the delegating physician, and the patient
education process does not require the medical assistant to
make any interpretive judgments or answer any questions
from the patient or patient representative that require a
diagnosis, assessment, or evaluation. Medical assistants
should not go beyond the patient education information that
has been approved by the physician.” “Frequent Questions
about Medical Assistants’ Scope of Practice,” CMA
Today, March-April 2012, Donald A. Balasa.

19. • “Are medical assistants permitted to triage patients? In order to answer
this question correctly, it is essential that terms be precisely defined and
thoroughly understood. In interacting with patients or their
representatives—by telephone or in person—medical assistants are
allowed to convey verbatim physician-approved information and
directions without exercising independent professional judgment or
making clinical assessments or evaluations. This communication process is
frequently called screening. Communication that does require the health
professional to exercise independent judgment or to make clinical
assessments or evaluations is frequently called triage. The general legal
principle is that physicians are allowed to delegate screening, but not
triage, to competent and knowledgeable medical assistants working under
their direct supervision in outpatient settings.” “Frequent Questions about
Medical Assistants’ Scope of Practice,” CMA Today, March-April
2012, Donald A. Balasa.