Regulatory and Legislative Letters

CRNA Practice Discloser and Consent - Anesthesia and/or Perioperative Pain Management (analgesia)
January 2012
In 2012, a new form for use for anesthesia and pain management was established in rule which appears in 25 TAC 601.9. For more information, view the Civil Practice and Remedies Code 74:101 to 74.107, which creates and governs the Texas Medical Disclosure Panel. 

JCAHO on CRNAs as Licensed Independent Practitioners (pdf)
November 12, 2003
The Joint Commission on Accreditation of Healthcare Organizations authored letters in 1996 and in 2003 that outlined certain interpretations to CRNAs, including the survey process regarding CMS requirements.

Texas Board of Nursing (BON) [formerly Board of Nurse Examiners, BNE]

Advanced Practice Registered Nurse (APRN) Licensure (pdf)
February 24, 2014
During the 83rd Legislative Session, Senate Bill (SB) 406 by Senator Jane Nelson made changes to regulatory terminology, including the use of a new term, “Advanced Practice Registered Nurse (APRN)”. The BON issued a letter explaining these new changes.

Update (6/16/15): As of this date, the BON has re-certified this as true for current CRNA practice. 

Prescriptive Authority and Controlled Substance Registration Numbers (pdf)
December 23, 2009
In 2009, the BON issued a letter clarifying prescriptive authority and controlled substance registration for CRNAs. Statute permits CRNAs to select, obtain and administer anesthesia and anesthesia-related medications and apply appropriate medical devices necessary to accomplish the order and maintain the patient within a sound physiological status. The CRNA may carry out these functions pursuant to a physician’s order for anesthesia or an anesthesia-related service that does not have to be drug-specific, dose-specific, or administration technique-specific.

Update (6/30/15): As of this date, the BON confirmed that content within the letter remains in effect and accurate. As of note, with the increasing number of pain management clinics and CRNA interest in operating within this role, outside of anesthesia-related services, the following would apply: Regarding pain management clinics and CRNA practice in a pain management clinic that is separate from traditional anesthesia-related services: Review of Board Rule 228 Pain Management. CRNAs wishing to practice within a pain management clinic delivering care that is not related to anesthesia services will require Prescriptive Authority from the Board of Nursing, as well as DPS and DEA registrations for the provision of controlled substances, in addition to a protocol or collaborative agreement with a delegating physician.

Pain Management Services (pdf)
April 17, 2006 
In 2006, the BON provided a letter that is specific to pain management that is within the realm of anesthesia or anesthesia-related services. This letter specifies that while CRNAs must have a physician’s order to administer anesthesia or an anesthesia-related service, there is no statutory requirement that the order specify the drugs, dosages, or routes of administration because these functions are within the CRNAs scope of practice. 

Update (7/31/15): As of this date, the BON certified that the information contained within the letter itself is accurate, but is more or less duplicative of the “BON Outlines CRNA Practice in Texas” letter provided below. Of note: A larger issue regarding the provision of “pain management”, has drawn the eye of authorities and regulators alike. Because of the eruption of “pill mills” and “pain management clinics”, the Board of Nursing in 2014 adopted rules related to Pain Management. Please see Board Rule 228.1 Pain Management. 

BON Outline on CRNA Practice in Texas (pdf)
December 13, 2004
In 2004, the BON issued a letter outlining the practice of CRNAs in the State of Texas. This document details settings in which CRNAs can practice, as well as physician supervision and delegation practices. For more information see: MPA 157.058. 

Update (5/26/15): As of this date, the BON has re-certified this as true for current CRNA practice.

BON States That CRNA Supervision is Not Required (pdf)
December 12, 1995
In 1995, the BON issued a letter clarifying physician supervision over CRNAs. This letter states that CRNAs may administer anesthesia and anesthesia-related services pursuant to a physician order and consistent with medical staff bylaws or policies and when doing so are not required to be supervised by a physician.

Update (7/31/15): As of this date, the BON has re-certified this as true for current CRNA practice.

BON States That CRNAs Can Give Perioperative Orders (pdf)
March 20, 1995 
In 1995, the BON issued a letter outlining CRNA practice as it relates to perioperative orders. This document states that CRNAs may be credentialed to write orders outside of the operating room, such as the recovery room. This letter provides more detail on other circumstances.

Update (7/31/15): As of this date, the BON has re-certified this as true for current CRNA Practice. Of note: Perioperative orders are those that are directly related to the immediate pre and post-operative phases and the anesthesia-related service provided. The surgeon or physician should be providing complete orders post-operatively for the patient upon transfer to an inpatient unit or upon discharge from the facility.

Legal and Legislative 

Texas OAG Letter to TMB - Maintains Request TMB Correct FAQ Misstatements
May 13, 2021
In 2021, The Office of the Attorney General issued a letter to Texas Medical Board (TMB) seeking to correct a previous letter stating a member testified on HB 2029. While the letter corrected their previous statement noting the TMB did not testify at the HB 2029 hearing, it continues to uphold the request for the TMB to revise their FAQs to reflect the most current guidance in Opinion No. 0371-KP.

Texas OAG Letter to TMB - Requests TMB Correct Misstatements
April 9, 2021
In 2021, The Office of the Attorney General sent a letter to the Texas Medical Board (TMB) seeking to address misstatements regarding the recent Opinion No. 0371-KP. The letter addressed both the supervision of CRNAs and the presence requirement in the Health & Safety Code.

Texas AG Opinion KP-0353 maintains the status quo
February 9, 2021
In 2021, Texas Attorney General Ken Paxton issued an Opinion, regarding “whether chapter 157 of the Occupation Code requires a physician to provide any level of supervision to a certified registered nurse anesthetist to whom the physician has delegated authority, and the potential liability for such delegation.”, and maintained the status quo for CRNAs in Texas.

Texas AG Opinion KP-0266 maintains the status quo
September 5, 2019
In 2019, Texas Attorney General Ken Paxton issued an Opinion, reaffirming JC-0117, which stated that CRNA supervision is not required, and maintaining the status quo for CRNAs in Texas.

Texas AG Opinion JC-0117 CRNA supervision not required
September 28, 1999

In 1999, Texas Attorney General John Cornyn, issued an Attorney General (AG) Opinion stating that CRNA supervision is not required.

Legislative Intent of SB 673 CRNA Practice Not Delegated Medicine 
May 5, 1997
During the 74th Legislative Session, Representative Hugo Berlanga, passed legislation (Senate Bill 673) aimed to provide additional support to rural areas to attract adequate health care providers to rural settings and give them the support necessary to retain them in rural practices and to increase facilities and services to the elderly and disabled populations in rural areas. In an effort to provide clarity for all stakeholders, Representative Berlanga issued a letter stating the legislative intent of SB 673, which clarified that CRNA practice is not delegated medicine.