By Jessica Ray, DNP, CRNA, VANA President
The Nurse Practice Act and CRNA Practice
Have you ever wondered which laws, regulations, and professional standards shape your practice as a Nurse Anesthesiologist in the Commonwealth of Virginia? The truth is that CRNA practice is guided by several key authorities, including the Virginia Nurse Practice Act, federal law, facility bylaws, and AANA standards. Together, these sources help define scope of practice, practice models, and setting-specific requirements. Read on for an in-depth overview of how each one affects CRNA practice in Virginia.
What does the Virginia Nurse Practice Act (NPA) say about CRNA practice?
Every state has an NPA that establishes and regulates how nursing is practiced within that state. Under the Virginia NPA, CRNAs can provide “the full spectrum of anesthesia and anesthesia-related care for individuals across the lifespan from healthy through all recognized levels of acuity, including persons with immediate, severe, or life-threatening injuries or illnesses in a variety of settings,” commensurate with our training, education, and standards defined by AANA.1,2 In a nutshell, Virginia law allows CRNAs to practice to the full scope of practice recognized by the AANA. You can access this information by visiting AANA.com and logging in with your membership credentials.
What does the Virginia NPA say about supervision?
Virginia law currently requires CRNAs to be supervised by a licensed physician, podiatrist, or dentist. In practice, that supervision may look different depending on the setting. For example, some CRNAs are supervised by a physician anesthesiologist in a care team model. Other CRNAs may work with a surgeon in a CRNA-only model, while some may work with a gastroenterologist in a GI office performing colonoscopies.
Unlike Virginia Nurse Practitioners and Nurse Midwives who can practice autonomously after meeting specified practice requirements, CRNAs in Virginia currently cannot practice without supervision. However, Virginia law does not define what “supervision” means, what documentation is required, or how supervision should occur daily. As a result, facilities may interpret and apply the requirement differently, including using practice agreements.
VANA has successfully opposed past legislation that would have expanded or intensified CRNA supervision requirements. At the same time, Virginia CRNAs continue working to modernize the Virginia Code by removing the word “supervision” altogether. This remains a high priority for both VANA and AANA.
What is a practice agreement and do CRNAs require one in Virginia?
A practice agreement defines the relationship between an advanced practice provider and their supervising physician, including their scope of practice. The Virginia NPA does not require a practice agreement for CRNAs, although an employer or facility may choose to require one.
Do CRNAs have prescriptive authority in Virginia?
In 2020, CRNAs in Virginia gained prescriptive authority for Schedule II through Schedule VI controlled substances and devices during the periprocedural period. The term “periprocedural” refers to the time beginning before a procedure and continuing until the patient is discharged. This authority marked a major step forward for the profession because CRNAs do not need a separate license to prescribe or procure medications during this period.
Federal Law and CRNA Practice
What does federal law say about CRNA practice?
Federal law generally leaves CRNA scope of practice and supervision requirements to the states. That means Virginia determines the state-level rules that govern how CRNAs may practice, including whether supervision is required.
At the same time, the Centers for Medicare & Medicaid Services (CMS) sets Medicare reimbursement requirements. Facility reimbursement falls under Medicare Part A, while physician and CRNA professional services fall under Medicare Part B.
For facilities to bill under Medicare Part A for CRNA services, CMS requires CRNAs to be supervised by a physician, though not necessarily by a physician anesthesiologist. Federal law also gives states the option to “opt out” of this Medicare Part A supervision requirement.
What is the difference between removal of supervision and CRNA opt-out?
“Supervision removal” refers to eliminating the state-level statutory requirement that CRNAs must be supervised by physicians, podiatrists, or dentists.
“Opt-out” is different. It applies specifically to CMS Medicare reimbursement requirements. In 2001, CMS ruled that state governors could “opt-out” of the CRNA supervision requirements for facility reimbursement under Part A. As of now, 27 states and Guam have opted out of this federal requirement; Virginia is not one of them.
State-level removal of supervision must occur BEFORE opt-out.
How is medical direction different from supervision?
“Medical direction” is often used informally to describe an anesthesia practice model, such as a hospital’s physician-led care team model. Technically, however, medical direction is a CMS Medicare Part B billing term for medically directed anesthesia services. To qualify for this reimbursement model, the practice must meet all seven components of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA).
“Supervision” is also used in more than one way. For Medicare Part B billing, “medical supervision” applies when the seven TEFRA components for medical direction are not met and a physician is involved in the care. Separately, “CRNA supervision” is used as a regulatory term in five states (including Virginia) to maintain physician involvement in patient care. VANA uses “supervision” to refer to Virginia’s statutory supervision requirement for CRNAs unless otherwise specified.
Facility Bylaws and CRNA Practice
How do my facility bylaws affect my practice?
Where you practice has a significant impact on how you practice. Facility bylaws and privileges granted during credentialing determine the details of the facility’s anesthesia practice model and what CRNAs are authorized to do within that setting, including their scope of practice.
Facilities must comply with Virginia’s supervision requirement. Still, they can choose which anesthesia practice model they use and what a CRNA’s scope of practice looks like at their facility. Currently, facilities can define what supervision looks like or require a practice agreement without the state’s input. Because of this, when supervision is removed from Virginia statute, hospital bylaws may still require supervision by a physician or physician anesthesiologist.
Joint Boards and CRNA Practice
What does it mean to be licensed by a Joint Board of Medicine and Nursing?
In Virginia, RN licensure is issued by the Board of Nursing. However, APRN licensure is issued by the Joint Board of Medicine and Nursing, a six-member board made up of three physicians and three APRNs. The Joint Board members guide all APRN professional practices and participate in disciplinary proceedings.
Virginia is the only state where CRNAs are jointly licensed by both a Nursing and Medical Board. In almost every other state across the country, APRN licensure, regulation of professional practice, and disciplinary actions occur under a sole board of nursing without physician oversight. Alabama and North Carolina have a Joint Board, but the licensing in those states does not apply to CRNAs.
Why does licensure by the Joint Board matter?
The current structure and purpose of the Joint Board of Medicine and Nursing impacts your practice as a CRNA in Virginia. Joint licensure prevents Virginia from participating in a nationwide APRN compact. Furthermore, the state’s statutory supervision requirement prevents any APRN from joining the compact, and Virginia’s ability to pursue a CRNA opt-out of CMS’s Medicare Part A requirements.
Although there have barriers to achieving more autonomy in CRNA practice in Virginia, progress is being made. In 2025, Virginia Senate Bill 351 proposed moving the licensure of APRNs solely under the Board of Nursing, but the bill ultimately did not pass. While VANA was not the sponsor of the bill, the association wholeheartedly supports moving APRN practice under a singular board of nursing.
This year, the legislature approved a budget amendment directing the Department of Health Professions to convene a group of stakeholders to consider whether to modernize or eliminate the Joint Boards. VANA is taking an active role in the workgroup and is also continuing to advocate for the dissolution of the Joint Boards and the removal of supervision from the statute.
If you ever have questions about the laws and regulations affecting CRNA practice in Virginia, please visit the new VANA website or reach out to the GRC (Government Relations Committee) and anyone in VANA leadership. We are here and happy to help you!
1https://www.dhp.virginia.gov/Boards/Nursing/PractitionerResources/AdvancedPracticeRegisteredNurse/
2https://law.lis.virginia.gov/admincode/title18/agency90/chapter30/section121/