Can a Tennessee physician give spinal injections in an office or clinic that is not licensed as a health-care facility, without being board certified in pain management?

Subject

Opinion No. 14-49, Administering Spinal Injections in Unlicensed Settings, April 23, 2014

Plain-English summary

Senator Joey Hensley, M.D., asked whether a licensed Tennessee physician who could give spinal injections in a licensed health-care facility could also give them in an unlicensed setting without meeting the board-certification rules in Tenn. Code Ann. § 63-6-244. The AG said no.

§ 63-6-244 defines "interventional pain management" as "the practice of performing invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine in any setting not licensed under title 68, chapter 11." Title 68, chapter 11 is the licensing chapter for health-care facilities like hospitals, ambulatory surgical centers, and similar institutions.

A licensed physician may practice interventional pain management only by meeting one of five statutory paths in § 63-6-244(a):

1. Board certification through one of the listed ABMS pathways (including the "other board certification" subspecialty option in (a)(1)(F) for physicians who have completed an ABMS subspecialty board in pain medicine or an ACGME-accredited pain fellowship);
2. Recent graduate with practice relationship with a board-certified physician (the (a)(2) pathway);
3. Board certification through ABPS/AAPS;
4. Service as a clinical instructor in pain medicine at an accredited Tennessee training program; or
5. Active pain-management practice in an accredited clinic.

The AG reasoned step-by-step: a spinal injection is an invasive procedure involving the spine. The statute itself confirms this by reference, since § 63-7-126(f) and § 63-19-107(5)(A) allow advanced-practice nurses and physician assistants to perform spinal invasive procedures only under the direct supervision of a licensed physician who is "actively practicing spinal injections." Practicing such a procedure in an unlicensed setting is therefore "interventional pain management" within § 63-6-244(b), and a physician who does not meet one of the five (a) requirements may not do it.

Currency note

This opinion was issued in 2014. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

Common questions

What is interventional pain management?

Under Tenn. Code Ann. § 63-6-244(b), it is the practice of performing invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine, or block of major peripheral nerves of the spine, in any setting not licensed under Title 68, Chapter 11. The "setting" condition is what makes it interventional pain management: the same procedure in a licensed hospital is not.

What counts as a "licensed setting" in Tennessee?

Title 68, Chapter 11 of the Tennessee Code is the Health Care Facilities chapter. It covers hospitals, ambulatory surgical centers, recovery care centers, and similar facilities. The Health Services and Development Agency administers the certificate-of-need process and the licensing of those facilities.

Why does the law distinguish between licensed and unlicensed settings?

The opinion does not discuss the legislature's reason for distinguishing between settings. It applies the statutory definition, which covers the specified invasive procedures in settings not licensed under Title 68, Chapter 11.

What if a physician is board certified, just not in pain management?

The opinion does not decide whether a particular medical specialty meets § 63-6-244(a)(1). It says three of the five statutory requirements involve some element of certification through the American Board of Medical Specialties or the American Board of Physician Specialties/American Association of Physician Specialties. Its footnote also describes an "other board certification" route in (a)(1)(F) for a physician who completed an ABMS subspecialty board in pain medicine or an ACGME-accredited pain fellowship.

What about CRNAs and PAs who give injections under physician supervision?

Tenn. Code Ann. § 63-7-126(f) (advanced-practice nurses) and § 63-19-107(5)(A) (physician assistants) allow these clinicians to perform invasive spinal procedures only under the direct supervision of a physician who is "actively practicing spinal injections." § 63-6-244(d) requires that supervising physician to meet the board-certification requirements of the statute. So the supervision pathway does not create an end-run.

What is the penalty for practicing interventional pain management without meeting one of the (a) pathways?

The opinion does not address penalties. It concludes only that a physician who does not meet the specified certification or other statutory requirements may not practice interventional pain management in an unlicensed setting.

Background and statutory framework

The 2012 General Assembly added § 63-6-244 and the companion provisions for advanced-practice nurses and physician assistants (§§ 63-7-126(f) and 63-19-107(5)(A)) in the same act, according to the opinion's second footnote.

The location of the procedure (an unlicensed setting) brings it within the opinion's definition of interventional pain management, even if the physician could perform the same procedure in a licensed facility. The physician must meet one of § 63-6-244(a)'s statutory requirements to practice it there.

Citations

• Tenn. Code Ann. § 63-6-244 (interventional pain management; five statutory pathways)
• Tenn. Code Ann. § 63-6-244(b) (definition of interventional pain management)
• Tenn. Code Ann. § 63-6-244(d) (supervising physician must meet board-certification requirements)
• Tenn. Code Ann. § 63-7-126(f) (advanced-practice nurses performing invasive spinal procedures under supervision)
• Tenn. Code Ann. § 63-19-107(5)(A) (physician assistants performing invasive spinal procedures under supervision)
• Title 68, Chapter 11 (health-care facility licensing)

Source

• Landing page: https://www.tn.gov/attorneygeneral/opinions.html
• Original PDF: https://www.tn.gov/content/dam/tn/attorneygeneral/documents/ops/2014/op14-049.pdf

Original opinion text

STATE OF TENNESSEE
OFFICE OF THE ATTORNEY GENERAL
April 23, 2014
Opinion No. 14-49
Administering Spinal Injections in Unlicensed Settings

QUESTION

Is a licensed physician who is permitted to administer spinal injections in a licensed health-care facility also permitted to give spinal injections in an unlicensed setting, even though the physician is not board certified as required by Tenn. Code Ann. § 63-6-244?

OPINION

No. Unless a licensed physician is board certified by one of the certifying organizations identified in Tenn. Code Ann. § 63-6-244, or meets one of the other statutory requirements, the physician may not practice "interventional pain management," which by definition involves administering spinal injections in an unlicensed setting.

ANALYSIS

Tenn. Code Ann. § 63-6-244 provides that a licensed physician may practice "interventional pain management" only if the licensee meets one of the five statutory requirements. Three of these involve some element of board certification through the American Board of Medical Specialties or the American Board of Physician Specialties/American Association of Physician Specialties. § 63-6-244(a)(1)-(3). The other two would allow a licensed physician to practice interventional pain management if he or she serves as a clinical instructor in pain medicine at an accredited Tennessee training program or has an active pain-management practice in an accredited clinic. Id. § 63-6-244(a)(4)-(5). Interventional pain management under this statute is "the practice of performing invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine in any setting not licensed under title 68, chapter 11." Id. § 63-6-244(b).

1 Subdivision (a)(2) applies to a recent graduate who is not yet eligible for board certification, requiring a practice relationship with a physician who is board certified, and subdivision (a)(1)(F) allows for “other board certification” if the physician has completed an ABMS subspecialty board in pain medicine or a pain fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).

A spinal injection is an invasive procedure involving the spine. See Tenn. Code Ann. §§ 63-7-126(f), 63-19-107(5)(A) (providing that advanced-practice nurses and physician assistants may perform invasive procedures involving the spine only under the direct supervision of a licensed physician "who is actively practicing spinal injections"). Practicing such a procedure in an unlicensed setting thus constitutes "interventional pain management," which a licensed physician may not do unless he or she is board certified as provided by the statute or meets one of the other statutory requirements.

2 Both of these statutory provisions were added as part of the legislation that added § 63-6-244. See 2012 Tenn. Pub. Acts, ch. 961, §§ 1, 3-4; see also Tenn. Code Ann. § 63-6-244(d) (requiring physician who provides direct supervision of advanced-practice nurse or physician’s assistant to meet the board-certification requirements of the statute).

ROBERT E. COOPER, JR.
Attorney General and Reporter

JOSEPH F. WHALEN
Acting Solicitor General

SARA E. SEDGWICK
Senior Counsel

Requested by:
The Honorable Joey Hensley, M.D.
State Senator
309 War Memorial Building
Nashville, Tennessee 37243