Are Nurse Practitioners Practicing Medicine?

Carolyn Buppert, MSN, JD

Disclosures

December 02, 2015

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Question

After being licensed, a NP can diagnose, order tests, and treat patients. Isn't this practicing medicine?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Nursing or Medicine?

Here is a question from a nurse practitioner (NP) student: "After being licensed, a NP can diagnose, order tests, and treat patients. Isn't this practicing medicine? Or is it advanced practice nursing? What is the difference?"

In some states, the definitions of "practice of medicine" and "practice of advanced practice nursing" overlap. In other states, diagnosis and treatment are the practice of medicine, with advanced practice nurses authorized to perform some medical functions, usually under specified terms.

Every state has a law defining "the practice of medicine" within that state. For example, North Carolina defines the practice of medicine as:

Offering or undertaking to prescribe, order, give, or administer any drug or medicine for the use of any other individual. Offering or undertaking to prevent or diagnose, correct, prescribe for, administer to, or treat in any manner or by any means, methods, or devices any disease, illness, pain, wound, fracture, infirmity, defect, or abnormal physical or mental condition of any individual, including the management of pregnancy or parturition.[1]

Some states, and the District of Columbia, define diagnosis and treatment as the "practice of advanced practice nursing." For example, in the District of Columbia, "practice of advanced practice nursing" means the performance of advanced-level nursing actions, with or without compensation, by a licensed registered nurse with advanced education, knowledge, skill, and scope of practice who has been certified to perform such actions by a national certifying body acceptable to the Board of Nursing. The practice of advanced practice registered nursing includes advanced assessment, medical diagnosis, prescribing, selecting, administering and dispensing therapeutic measures, treating alterations of health status and carrying out other functions...."[2]

The Legal Practice of Medicine

One must look at state law to decide whether medical diagnosis and treatment constitute the practice of medicine, whether NPs are authorized to practice specified aspects of medicine under delegation from a physician, or whether medical diagnosis and treatment are within the definition of advanced practice nursing.

Let's compare three state laws on nurse NP practice:

North Carolina. In North Carolina, an NP is defined as a currently licensed registered nurse approved to perform medical acts consistent with the nurse's area of NP academic educational preparation and national certification under an agreement with a licensed physician for ongoing supervision, consultation, collaboration, and evaluation of medical acts performed.[3]

So, in North Carolina, diagnosis and treatment are not considered advanced practice nursing, but rather the practice of medicine. A NP may perform these medical acts, if there is a collaboration agreement with a supervising physician.

South Carolina. In addition to those activities considered the practice of registered nursing, an advanced practice registered nurse (APRN) may perform delegated medical acts.[4]

In South Carolina, the advanced practice nurse can, if a physician delegates his or her authority, perform certain acts within the practice of medicine.

New Hampshire. The APRN's scope of practice, with or without compensation or personal profit, shall be limited to[5]:

  • Performing acts of advanced assessment, diagnosing, prescribing, selecting, administering, and providing therapeutic measures and treatment regimens;

  • Obtaining consultation, planning, and implementing collaborative management, referral, or transferring the care of the client as appropriate; and

  • Providing such functions common to a NP for which the APRN is educationally and experientially prepared and which are consistent with standards established by a national credentialing or certification body recognized by the National Council of State Boards of Nursing and approved by the board in the appropriate APRN role and specialty.

In New Hampshire, the APRN can perform functions "common to a NP," including diagnosing and treating, and there is no differentiation of these acts into the categories of nursing or medicine.

Therefore, a NP needs to follow the specific dictates of his or her state law. Discussion about whether a function or collection of functions theoretically is "medicine" or "nursing" is not an efficient use of time, in my opinion. Both physicians and APRNs perform functions that have historically been described as "the practice of medicine" but now are within the realm of "advanced practice nursing."

For the purposes of billing NP services, NPs will want to refer to their services as "physician services," because third-party payers reimburse for "physician services," but not "nursing services." "Nursing services" are covered in the payment to hospitals for hospital services, but are not reimbursed separately. In office practice, nursing services are not reimbursed at all. Physician services are reimbursed separately, regardless of the setting in which they are performed. If one maintains that the functions of an advanced practice nurse are "nursing," then a NP can't bill third-party payers for those services.

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