Can a Washington occupational therapist legally perform sharp debridement, the cutting away of dead tissue from a wound, as part of wound care?
Plain-English summary
Dr. Bernstein, the chair of the Podiatric Medical Board, asked the AG whether sharp debridement is within the scope of practice for occupational therapists in Washington. Sharp debridement is the removal of dead, contaminated, or adherent tissue from a wound using a scalpel or scissors, in order to expose healthy tissue and improve healing. The question arose because the Occupational Therapy Practice Board was considering an interpretive statement saying that occupational therapy "include[s] sharp debridement and wound care management." A revised draft narrowed that to "non-surgical" sharp debridement.
The AG's answer was no. Sharp debridement falls outside the statutory definition of occupational therapy in RCW 18.59.020(2), and the Board's proposed interpretation was not supportable.
The reasoning followed the structure of the definition. The first part is a general statement: occupational therapy is "the scientifically based use of purposeful activity with individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the aging process in order to maximize independence, prevent disability, and maintain health." Read in isolation, that language is broad enough to potentially cover almost anything done in service of patient health, including the practice of medicine. The legislature could not have intended that, given that occupational therapists have their own licensing track distinct from physicians.
The second part of the definition lists "occupational therapy services" as a non-exhaustive but illustrative set: designed activities and exercises for neurodevelopmental, cognitive, perceptual motor, and psychomotor functioning; manual muscle and sensory integration testing; teaching daily living skills; developing prevocational, play, and avocational capabilities; designing, fabricating, or applying orthotic and prosthetic devices and adaptive equipment; and adapting environments for the handicapped. Under the statutory-construction rule that general terms take meaning from associated specific terms (Burns v. City of Seattle), the listed services define the kind of practice the legislature intended. None of them resemble cutting tissue with a sharp instrument. The list speaks of exercises, tests, teaching, fitting devices, and adapting environments. Sharp debridement, even in its less invasive forms, is qualitatively different.
The AG also pointed to RCW 18.59.100, which requires occupational therapists to refer "medical cases" to a physician for direction and prohibits treatment of a medical case absent a referral from a physician, osteopathic physician, podiatric physician, naturopath, chiropractor, physician assistant, psychologist, or advanced registered nurse practitioner. That referral duty implies that occupational therapy does not itself extend into the medical-treatment territory those other professions occupy.
On the Board's narrower draft (limiting to "non-surgical" sharp debridement), the AG was unmoved. The medical literature distinguishes surgical from sharp debridement only by degree: surgical debridement is for large, deep, painful, or urgent cases; sharp debridement is a more limited bedside procedure. Drawing a legal line on that gradient is a policy choice for the legislature, not a Board interpretation. If the legislature wanted occupational therapists to perform sharp debridement, it could amend the definition.
Currency note
This opinion was issued in 2010. 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 an "interpretive statement" and is it binding?
Per RCW 34.05.010(8), it is an agency's stated opinion of what a statute means. Per RCW 34.05.230(1) and Washington Educ. Ass'n v. Pub. Disclosure Comm'n, interpretive statements are advisory rather than binding. They are not rules and have "no legal or regulatory effect," but they signal how the agency intends to interpret the law going forward.
What is the difference between sharp debridement and surgical debridement?
The opinion treated them as points along a continuum: surgical debridement involves large, deep tissue damage, requires anesthesia, and typically uses scalpels, scissors, and forceps in a more invasive setting. Sharp debridement is "usually a minor bedside procedure, with limited removal of nonviable tissue." Both methods are selective and require an extensive understanding of underlying anatomical structures.
Can an occupational therapist do anything wound-related?
The opinion noted that the listed services include designing, fabricating, or applying selected orthotic and prosthetic devices and adaptive equipment, suggesting some role in patient recovery from or adaptation to a wound. The AG declined to map the full range of legitimate wound-related OT activity because the question concerned sharp debridement specifically. OTs perform "certain wound-related functions"; sharp debridement is just not among them.
Did Medicare-billing rules support the OT scope?
The American Occupational Therapy Association argued that Medicare reimburses OTs for certain limited debridement procedures performed without anesthesia. The AG accepted that as factually true but rejected its relevance: federal Medicare billing categories do not change the meaning of a Washington state-law scope-of-practice definition.
Why was the Board's distinction between surgical and non-surgical sharp debridement insufficient?
Because the statutory definition does not draw that line. The line between minor bedside debridement and surgical debridement is a clinical and policy judgment about which medical professionals possess the requisite training. The Board was effectively asking the AG to read into the statute a distinction the legislature did not write. Per Kilian v. Atkinson, courts (and AGs) "may not read into a statute matters that are not in it."
Is the legislative-policy point an open invitation to expand the scope?
Yes. The opinion stated that "[t]he question of which medical professionals possess the requisite training and skill is a policy question best addressed by the legislature." The Board's draft itself contemplated that legislation on the subject was anticipated at the 2010 session.
Background and statutory framework
Washington licenses occupational therapists under RCW 18.59. The substantive scope-of-practice definition is in RCW 18.59.020(2). The licensing requirements are in RCW 18.59.050, with rule-implementation under WAC 246-847. The referral duty in RCW 18.59.100 is the connective tissue between OT and the broader healing-arts statutes.
The construction issue turned on the standard tools: plain meaning first, statutory-context second, the Burns v. City of Seattle "associated words" canon, and the Kilian v. Atkinson restraint against reading-in. The Department of Ecology v. Campbell & Gwinn rule that statutory meaning is "discerned from all that the Legislature has said in the statute and related statutes" anchored the cross-reference to the referral duty.
The "interpretive statement" framework comes from the Administrative Procedure Act. Agencies may publish their reading of statutes (RCW 34.05.010(8)), but those readings have no binding legal effect (RCW 34.05.230(1)).
Citations and references
Statutes and rules:
- RCW 18.59.020(2) (definition of occupational therapy)
- RCW 18.59.031 (license requirement)
- RCW 18.59.050 (licensing requirements)
- RCW 18.59.100 (referral duty in medical cases)
- RCW 18.71.011 (practice of medicine)
- RCW 18.25.005 (practice of chiropractic)
- RCW 34.05.010(8) (interpretive statement defined)
- RCW 34.05.230(1) (interpretive statements not binding)
- WAC 246-847-010(13), -040
Cases:
- Washington Educ. Ass'n v. Pub. Disclosure Comm'n, 150 Wn.2d 612, 80 P.3d 608 (2003)
- Kilian v. Atkinson, 147 Wn.2d 16, 50 P.3d 638 (2002)
- Burns v. City of Seattle, 161 Wn.2d 129, 164 P.3d 475 (2007)
- Simpson Inv. Co. v. Dep't of Revenue, 141 Wn.2d 139, 3 P.3d 741 (2000)
- McGinnis v. State, 152 Wn.2d 639, 99 P.3d 1240 (2004)
- State v. Wilson, 11 Wn. App. 916, 528 P.2d 279 (1974)
- Ellestad v. Swayze, 15 Wn.2d 281, 130 P.2d 349 (1942)
- Dep't of Ecology v. Campbell & Gwinn, L.L.C., 146 Wn.2d 1, 43 P.3d 4 (2002)
- York v. Wahkiakum Sch. Dist. 200, 163 Wn.2d 297, 178 P.3d 995 (2008)
Source
Original opinion text
Attorney General Rob McKenna
OCCUPATIONAL THERAPISTS—Scope Of Practice Of Occupational Therapy
The scope of practice for occupational therapists does not include the practice of sharp debridement.
January 15, 2010
David M. Bernstein, DPM
Chairman, Podiatric Medical Board
Department of Health
PO Box 47852
Olympia, WA 98504
Cite As:
AGO 2010 No. 2
Dear Dr. Bernstein:
By letter previously acknowledged, you have requested our opinion on the following paraphrased question:
Is the practice of sharp debridement within the scope of practice for occupational therapists?
BRIEF ANSWER
No. Sharp debridement is not within the scope of practice for occupational therapists.
ANALYSIS
The scope of practice for occupational therapists is governed by the statutory definition of occupational therapy. That definition provides:
"Occupational therapy" is the scientifically based use of purposeful activity with individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the aging process in order to maximize independence, prevent disability, and maintain health. The practice encompasses evaluation, treatment, and consultation. Specific occupational therapy services include but are not limited to: Using specifically designed activities and exercises to enhance neurodevelopmental, cognitive, perceptual motor, sensory integrative, and psychomotor functioning; administering and interpreting tests such as manual muscle and sensory integration; teaching daily living skills; developing prevocational skills and play and avocational capabilities; designing, fabricating, or applying selected orthotic and prosthetic devices or selected adaptive equipment; and adapting environments for the handicapped. These services are provided individually, in groups, or through social systems.
RCW 18.59.020(2). State law prohibits practicing occupational therapy without a license. RCW 18.59.031.
Your question involves a proposed "interpretative statement" under consideration by the Occupational Therapy Practice Board (Board). You provided a copy of a draft with your opinion request. That draft statement concludes: "The board is interpreting the occupational therapy scope of practice (RCW 18.59.020) to include sharp debridement and wound care management." We understand that, although the Board has not yet acted upon this draft interpretive statement, a more recent draft limits the conclusion to "non-surgical" sharp debridement. You ask whether the Board would be correct in adopting this construction of state law.
Although the draft interpretive statement, and your request for our opinion, both refer to "wound care" in addition to "sharp debridement," our analysis focuses on sharp debridement. We do so because your request and the comments we have received regarding your request emphasize that the practice of sharp debridement is the focus of concern. "Wound care" is the more general of these two terms, and includes sharp debridement, among other practices. As described below, occupational therapists perform certain wound-related functions, but because the focus of your concern is on the practice of sharp debridement, we do not attempt to comprehensively address that role.
You ask whether the practice of "sharp debridement" falls within this statutory definition of occupational therapy. "Debridement" means "the surgical removal of lacerated, devitalized, or contaminated tissue." Webster's Third New International Dictionary of the English Language 582 (2002). You explain, in posing your question, that "[s]harp debridement is the removal of dead or necrotic tissue or foreign material using a scalpel or scissors from and around a wound to expose healthy tissue and optimize wound healing."
We understand that the Occupational Therapy Practice Board is currently considering the adoption of an "interpretive statement" on wound care management and sharp debridement, and a draft of this statement gives rise to your question. An interpretive statement is an agency's opinion of the meaning of a statute or other authority. RCW 34.05.010(8). Such statements are not rules and are advisory rather than binding. RCW 34.05.230(1); Washington Educ. Ass'n v. Pub. Disclosure Comm'n, 150 Wn.2d 612, 619, 80 P.3d 608 (2003) (interpretive statements "have no legal or regulatory effect"). If adopted, the interpretive statement would "serve only to aid and explain the agency's interpretation of the law." Id.
You ask whether the Occupational Therapy Practice Board's proposed interpretation of the law is correct. To answer this question, we return to the definition of "occupational therapy" set forth in statute. The definition is comprised of two parts. The first part sets forth a general statement of what the term "occupational therapy" means. It describes occupational therapy as, among other things, "using" "purposeful activity," including "treatment," "with" any individual who is "limited by physical injury" in order to "maintain health." RCW 18.59.020(2); see also WAC 246-847-010(13). Read broadly and in isolation, that language might suggest that the scope of practice for an occupational therapist is comparable to that of a physician. See RCW 18.71.011. This construction seems unlikely, given that the legislature saw the need to establish a separate licensing regime for occupational therapists as a distinct profession.
We may not construe the meaning of "occupational therapy" by referring to the first part of the statute in isolation. Kilian v. Atkinson, 147 Wn.2d 16, 21, 50 P.3d 638 (2002). The second part of the statutory definition enlightens the interpretation of "occupational therapy" by setting forth a nonexclusive list of "occupational therapy services." This list of services helps to construe the more general terms of the first part. Burns v. City of Seattle, 161 Wn.2d 129, 148, 164 P.3d 475 (2007); see also Simpson Inv. Co. v. Dep't of Revenue, 141 Wn.2d 139, 151, 3 P.3d 741 (2000) ("general terms, when used in conjunction with specific terms in a statute, should be deemed only to incorporate those things similar in nature or 'comparable to' the specific terms").
It, therefore, follows that the statutory definition of "occupational therapy" encompasses services that are similar to those listed in the second part of the definition, even if it is not strictly limited to those services. None of the services listed in the statute are similar to sharp debridement. The list speaks in terms of exercises, tests, the teaching of skills, and adapting environments. RCW 18.59.020(2). One element in the list explains that occupational therapists may design, fabricate, or apply certain orthotic or prosthetic devices, and the inclusion of this item in the list suggests that occupational therapy encompasses, at least to some extent, activities that relate in some general way to a patient's recovery from or adaptation to a wound. None of the listed services, however, suggest that occupational therapy includes a procedure, such as sharp debridement, that involves the cutting or removal of tissue with a sharp instrument.
The most recent draft of the interpretive statement, as noted above, narrows the Board's proposed interpretation of the statutory definition to include only "nonsurgical" sharp debridement. An argument might be offered in favor of this more limited inclusion of sharp debridement within the scope of practice of occupational therapy by noting the distinction between surgical and nonsurgical debridement. The statute itself, however, suggests no basis for such line-drawing in the guise of statutory construction. The question of which medical professionals possess the requisite training and skill is a policy question best addressed by the legislature.
This conclusion finds further support in an additional statute codified in the same chapter. See Dep't of Ecology v. Campbell & Gwinn, L.L.C., 146 Wn.2d 1, 11, 43 P.3d 4 (2002). In addition to defining "occupational therapy," the legislature has also established a duty for occupational therapists to refer certain matters to other medical professionals:
An occupational therapist shall, after evaluating a patient and if the case is a medical one, refer the case to a physician for appropriate medical direction if such direction is lacking. Treatment by an occupational therapist of such a medical case may take place only upon the referral of a physician, osteopathic physician, podiatric physician and surgeon, naturopath, chiropractor, physician assistant, psychologist, or advanced registered nurse practitioner licensed to practice in this state.
RCW 18.59.100. If an occupational therapist is presented with a "medical" case, he or she must refer the patient to a physician if medical direction is lacking. RCW 18.59.100. The occupational therapist is prohibited from treating such a patient unless referred by one of the listed medical professionals. RCW 18.59.100. This statute reflects legislative recognition that the scope of practice for occupational therapists does not extend to the medical treatment provided by the other medical professions listed in the statute.
We trust that the foregoing will be useful to you.
ROB MCKENNA
Attorney General
JEFFREY T. EVEN
Deputy Solicitor General