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Qheral &ate of ?aexae DAN MORALES ATTORNEY GENERAL September23,1996
Bruce A. Levy, M.D., J.D. ExecutiveDirector Texas State Board of AcupunctureExaminers 1812 Centre Creek Drive, Suite 300 P.O. Box 149134 Austin, Texas 787149134 Opiion No. DM-415
Re: Whetherthe practice of acupuncture is within the scope of practice for a licensed Texas chiropractor and related questions (RQ-853)

Dear Dr. Levy: You inform us that certain health-care practitioners, who are licensed as chiropractors but not as acupuncturists.1have been advertising that they perform. and presumablydo perform, acupuncture at their chiropracticclinics. You ask three questions in an attempt to determine whether this phenomenon indicates a violation of V.T.C.S. article 4495b, subchapter F, which governs the practice of acupuncture, or V.T.C.S. article 4512b, which governs the practice of chiropractic. Specifically, you seek our opinionregardingthe followingissues:

1. Whether the practice of acupuncture is within the scope of practice for a licensedTexas chiropractor72 2. Whether licensure as an acupuncturist is required for a licensedTexas chiropractorto engagein the practice of acupuncture? 3. If the answerto the first question is yes and the answer to the second question is no, whether advertising the practice of acupuncture by a licensed chiropractor violates statutes prohibiting false or misleadingadvertising if the chiropractor fails to indicate in the advertisement that he or she is not licensed by the Texas State Board of AcupunctureExaminers? We will begin by discussing the two statutes that are most relevant to your questions, V.T.C.S. article4495b, subchapterF, andV.T.C.S. article4512b. The legislature enacted subchapter F of article 4495b to provide for the

“establishment of statewide standards for the training, education, and discipline of

‘An antpunchvist

iaa QraaitiOnn ofacupmchur.See V.T.C.8. art.46’ 5b. 06.020).Bruce A Levy, M.D., J.D. - Page 2 (DM-415)

acupuncturists and for “an orderly system of regulating the practice of acupuncture.” V.T.C.S. art. 4495b, 8 6.01. See generuZ& Attorney General Opiion DM-336 (1995) at l-2 (summa&mg V.T.C.S. art. 495b, subch.P). Section 6.02(l) defines “acupuncture” as foliows: (A) the insertion of an acupuncture needle and the application

of moxibustionsto specific areas of the human body as a primary mode oftherapy to treat and mitigate a humancondition;and (B) the administrationof thermaJor electricaJtreatments or the recommendation of dietary guidelines, energy flow exercise, or dietary or herbal supplements in conjunction with the treatment describedby Paragraph (A) ofthis subdivision.*Footnotes added.] No individualmay practice acupuncture in this state unless he or she has obtained a license to practice acupuncture 6om the Board of Medical Examiners, upon the recommendationof the Board of Acupuncture Bxaminerss V.T.C.S. art. 4495b, 3 6.06; see also id. $5 6.05(a)(6), 6.10. A “health care profesSionallicensed under another subchapter” of the Medical Practice Act or another statute may practice acupunctu~ without obtaimng a kense from the Board of Medical Bxaminers,but only if the practice of acupuncture is “within the scope of’ the health care profesSional’ skense. Id. 8 6.03(a). Any individual who practices acupuncture without a license to practice

~~~on”ir’ [c]a~onbymauLF~acylindcros~dcotton~Eallcda~ QhCCd 011

thC SkiItand fid pt the top.” TAFER’SCycux~~~c MEBXL D~C~ONARY M-66 (Clayton L. Thomas, M.D., MPH, al.. 13Ib cd. 1977); see ah An&mm Y.Edlard, 498 F. Supp. 1038, 1043 11.14(S.D. Tcx. 1980). Moxibuslion is ‘[u]scd to produce c.umWnitation.” TABER’S ~YCUXEDIC MEDIC.%DICTIONARY

M&iBruce A Levy, M.D., J.D. - Page 3 (DM-415)

acupuncture or a license encompassingthe practice of acupuncture commits a class A misdemeanor. Id. 8 6.12(b). Section 1 of article 4512b, V.T.C.S., lists three acts constituting the practice of chiropractic. As amendedby the Seventy-fourthLegislature, section 1provides:

(a) A person shall be regarded as practicing chiropractic within the meaningofthis Act ifthe person: (1) uses objective or subjectivemeans to analyze, examine, or evaluate the biomechanical condition of the spine and musctdoskeletalsystem ofthe htmtanbody. (2) pet-forms

nonsurgica&

nonincisiveprocedures including but not limited to adjustment and manipulation, in order to improve the subluxation6complex or the biomechanics of the musculoskeletalsysteq or (3) holds himselfout to the public as a chiropractor of the human body or uses the term “chiropractor,” ‘chiropractic,”

“doctor of chiropractic,” ‘DC.,” or any derivative of those tetms in CoMection witb his name.’ Act of May 29. 1995. 74th Leg., RS.. ch. 965, 5 13, 1995 Tex. Sess. Law Serv. 4789, 4802 (footnotes added). Prior to the e&&e date of the 1995 amendments,article 4512b did not limitthe scope of chiropracticto only nonincisive,nonsurgicalprocedures.* See id. Section 13a of V.T.C.S. article 4512b, which the Seventy-fourth Legkkure also amended, see id. 5 18, 1995 Tex. Sess. Law Serv. 4789, 4803, explicitly excludes from the practice of chiropractic, among other things, “incisive or surgical procedures.” For purposesofarticle4512b,thephrase

‘%ubhxaIion” is “a panid didofxtia& a yeain” XVII t33ma13 E~ousti DICnONmY 42 (26 ed. 1989). VhcScvaity-fowthL@3latmiMertalIhewordnMtbcbumsnbody*~“asa dbpmctof and “or WCS the tam” See Ad ofhfay 29.1995,74tb Lg., R.S., cl~ 965, # 13.1995 Ta Seaa.Law Serv. 4789,4802 (amatdiqV.T.C.8. art. 4512b. 0 l(a)(3)). %QattiaIlar*Qriortolmmrfmcnt by tk Sevay-ftmttb Le&labq V.T.C.S. utick 4512b. mtuionl(a)(2)pnwidaithatanindikhl~~iftkibciDdividuat~

. . niaqam,oroIber~inoIdertolmQnweaubl~atlle~cadtbc nxtndoskelti syxten~” See Aa ofMay 29.1995.74th Leg. RS.. ch 965, p 13.1995 Ta Sets. JAW &IV. 4789.4802 @meding V.T.C.S. art. 4512b, P l(a)(2)).Bruce A Levy, M.D., J.D. - Page 4 (DM-415)

“incisiveor surgicalprocedure” includesbut is not limitedto making an incision into any tissue, cavity, or organ by any person or implement. It does not includethe use of a needle for the purpose of drawingblood for diagnostictesting.9 V.T.C.S. art. 4512b, 3 13a(b) (footnote added). A violation of article 4512b results in the revocation or ampension of a license, or the probation or reprimand of a licensee. V.T.C.S. art. 4512b, 8 14(a); see aJso id. 6 14a(l). The Texas Board of Chiropractic Firmminers may assess an administrative penalty in an amount not to exceed $1,000 for each day the violation occurs or continues. See id. 85 14(a), 19a(a). In addition, a person who violates article 4512b is liable to the state for a civil penalty of Sl,OOO for each day the violation occurs or continues. Id. 8 lww For purposes of this opinion, we assume a chiropractor practices acupuncture to improve the subluxationcomplex or the biomechanicsof the musculoskeletalsystem. See id. 5 l(a)(2). Central to our determination of whether the practice of acupuncture is “within the scope of’ a chiropractic license, see V.T.C.S. art. 4495b, $6.03(a), is a consideration of whether acupuncture is an “incisiveor surgical procedure” for purposes of section 13a(b) of article 4512b. lf acupuncture is an incisive or surgical procedure, article 4512b, section 13a(s)(l) excludesit from the practice of chiropractic, and a person who is licensed only as a chiropractor may not perform it.. The word “incisive” means “cutting; having the power of cutting.” TABER’ S C~cLopEDlc

MEDICAL

DICI’IONARY

I-12 (Clayton L. Thomas, M.D., M.P.H., ed., 13th ed. 1977). It also means “cutting with a sharp edge.” Vll THE CIEIRD EJIGIJSH DICTIONARY

796 (2d ed. 1989). The word “surgical”per&s to surgery, which is the “branch of medicine dealing with manual and operative procedures for correction of deformities and defects, repair of injuries, and diagnosis and cure of certain diseases.” TABER’ S CYCLOPEDIC

MEDICAL DICIIONARY.

supru, at S-130; see &o id at S-131 (defining ‘surgical”). For purposes of the Medical Practice Act, V.T.C.S. article 4495b, the legislature has defined the term

“surgery” to include “surgical services, surgical procedures, surgical operations, and the procedures described in the surgery section of the CommonProcedure Coding System ills adopted by the Health Care Fiicing Administrationof the United States Department of Health and Human Services.“t” V.T.C.S. art. 4495b. 8 l.O3(a)(l5).Bruce A Levy, M.D., J.D. - Page 5 (DM-415)

When interpreting a statute, a court must diligently attempt to ascertain legislative intent. Gov’t Code 3 312.005. Although we question whether a court ordinarily would classify acupuncture as “incisive”*t or “surgicaJ,“ts

we believethe legislatureintended that V.T.C.S. artjcle 4512b, section 13a(b)be construed to classifyacupuncture as an “incisive or surgical procedure”; we tiuther believe a court would reach a conclusion consistent with the legislative intent. The legislature expressly excluded fiorn the range of procedures that are incisive or surgical %e use of a needle for the purpose of drawing blood for diagnostic testing.” We deduce that the legiskre considered the use of a needle for the purpose of drawing blood to be an incisive or surgical procedure, and we find no distinctionbetween the use of a needlein a diagnostic ckcum&mce and the use of acupuncture needles. Additionally, we note that, during the Seventy-fourth Legislature, a witness described acupuncture as “a mildform of surgery” to the Senate Committee on Health and Human Setvices. See Hearings on S.B. 718 Before the Senate Comm. on Health and Human Sendces, 74th Leg., R.S. (Apr. 12,X95) (statement of Dee Ann Newbold, Texas Acupuncture AswciaUon) (tape available fbom Senate Statf Services). The legiskme may well have believed, therefore, that acupuncture was among those “incisive” and

“surgicaJ”procedures article 4512b, sections l(a)(2) and 13a(b) exclude gem the practice of acupuncture.

L’ COMSh8VCdCSdbCd **wpmccureua~~dtbe~ “**  **aAwpmchmSoc~ofKw.** v. KmLuz3ateEd. o/HeahgArts, 602 P.2d 1311.1311 (l&a. 1979). or “a &mncmiq~bodilyticriug” see People v. Amber, 349 N.Y.S.26 604. 610 (N.Y. Sup. Ct 1973), as well as an ?nsadon- &
‘manipuhtion” of wires of nce&q see **An&ewe** Y.Babd, 498 F. Sqp. 1038, 1043 (SD. Ta 1980); Peoplev. Roes, 514N.E.Zd993.993.994 (Ill. **1%7);AwpurchvrSoc~of?hn.,** 602P.2dat 1312;.Wate v.Rlch, 339N.E.Zd630.631 (Ohio **1975);Amber,** 349N.Y.S.2dat611. “Wefindno0~cl~~om1tthathuamskcdwlwtl~rtbcpndiceof~~e~ rar.&ay~tmt~~tcIhat~amundtbccaunbyCmnhy~ontbeimue. Forexample,thcSqremc

delmmedtbat~l6notaugayferpvporaofthcKao6assutatca kfaustvupnncturriSWt”~tOrparste~-ti6SWfWtkpcuporc,OfQCW&UjOIlfOI trratmcnfre~lactmwt or runoval of aQioted partr.”Awpvnchm Sot ), of Kan. Y. Kwwe StateEd. of Healing Arts. 602 P.2d 1311. 1315-16 &an. 1979); accord People v. Roar. **514**NE26 **993, 997**  **(Tll.** 1987); see &o Stute Y. Wan, 528 P.2d 594.5% (Or. 1974) (nnnmprizing wltboutKGMsidaing.lower OOUtl’StiIdiUgtIUlt~ didlWtCOMtltUtCllliWl6UIgCIy).OIlthCOtbbi3Od,thCW~COUttOfAQQWlSlISS&tWUiWdthUropoDchnesurgay bccauac it iwoks “the pwehation of human tima.” syotc v. Wilwn, 528 P.2d 279,281 (Wash Ct. AQQ.1974); accord Kelley Y. Rqickas, 270 N.W.2d 665.669 (Mich Ct. m. 1978) (citing Nets Reguhting the Pm&w ofAwpuncturr: Rewnt Devekpwn~ in Gd@mia, 7 U.C. DAVIS L. &V. 385, 391-92.3% (1974)); see also Che!?y Y.State FarmMU. Aufo. Ins. Co., 489 N.W.26 188,790 @fich. Ct. AQQ.1992) (citing Roguckar. 270 N.W.Zd 665); Cammwwalth Y. Schakber& 371 ALhI 544,547 n.6 (Pa.commw.ct 1977)@dicatingthatAtbxncyGcnaalof~~mncI~thst~ir augay iad fokkldcn to chifopracIorS).Bruce A Levy, M.D., J.D. - Page 6 (DM-415)

Furthermore., article 4495b. subchapter F suggests that the legislature believes acupuncturists shouldbe trained in accordancewith statewide standards, see V.T.C.S. art. 4495b, 5 6.01(l), and examinedby a state board, see id. 5 6.05(a). The legislature has establishedrequirements for an applicant for a license to practice acupuncture: among other things, the applicant must have completed 1,800 hours of instruction in subjects including bacteriology, physiology. symptomatology, meridian and point locations, and hygiene, and must have treated patients (with supervision)for at least two terms. See id. 8 6.07(c). We believe the legislature, in the interest of the public health, safety, and welfare, see id. 8 6.01(2), intended to except l?om the training and examination requirements only health care professionalswhose licenses clearly encompassthe practice of acupuncture. See id 5 6.03(a). In our opinion, the practice of chiropractic, as delineatedin V.T.C.S. article 4512b. section 1. does not clearly encompassthe practice of acupuncture. We accordingly conclude that V.T.C.S. article 4512b. section 1. which encompasseswithin the practice. of chiropractic only nonsurgical,nonincisiveprocedures. does not authorize a chiropractor to practice acupuncture. In answer to your Srst question. therefo~ the practice of acupuncture is not within the scope of practice for a licensed Texas chiropractor. Conversely, in answer to your second question, a licensed chiropractor must obtain a license to practice acupuncture if the chiropractor desires to practice acupuncture. You premise your last question on an a&native response to your first question and a negative response to your second question. We have reached the opposite conclusions. Consequently,we need not answeryour last question.Bmce A Levy, M.D., J.D. - Page 7 (DM-415)

SUMMARY Only a health care professional whose license clearly encompasses the practice of acupunchxe is excepted **from the**  training and exanktion requirements se-t forth for acupuncturists in V.T.C.S. article 4495b, subchapter F. The practice of chiropractic, as delineated in V.T.C.S. article 4512b, section 1, does not clearly encompass the practice of acupuncture. Accordingly, V.T.C.S. article 4512b, section 1, which authorizes a chiropractor to perform only nonsurgical, nonincisive procedures, does not authorize a chiropractor to practice acupuncture. Thus, the practice of acupuncture is not witbin the scope of practice for a licensed Texas chiropractor. Conversely, a licensed chiropractor must obtain a license to practice acupuncture if the chiropractor desiresto practice acupunctore.

DAN MORALES Attorney Generalof Texas
JORGEVEGA Fii Assistant Attorney General SARAHJ. SHIRLEY Chair, OpinionCommittee Frepared by KymberlyK. Oltrogge Assistaat Attorney General