News & Insights

Office-Based Surgery: I Have to Report What?

November 19, 2018

By Karen C. Duncan, RN, Attorney at Law


Office-Based Surgery: I Have to Report What?

Many healthcare providers likely don’t know that certain types of surgical procedures performed in an office require specialized record-keeping. The rules can be found in the Louisiana Administrative Code on Professional and Occupational Standards, LAC 46:XLV.7301. We’ve compiled several common questions and answers on the record-keeping requirements of office-based surgery.

First, do the office-based surgery rules apply to my office?

Yes, unless your office meets one of the following criteria:  

  • Licensed by Louisiana Department of Health
  • Accredited by The Joint Commission
  • Accredited by the American Association for the Accreditation of Ambulatory Surgery Facilities
  • Accredited by the Accreditation Association for Ambulatory Healthcare
  • A hospital and a physically separate outpatient department of a hospital
  • A facility that is Louisiana Department of Health license
  • A facility that is operated by the U.S. government

OK, my office does not have those licenses or accreditations. Looks like the office-based surgery rules apply. What counts as surgery under the law?  

Surgery is defined as:  

  • The excision or resection, partial or complete destruction, incision or structural alteration of human tissue by any means, (including lasers, pulsed light, radio frequency or medical microwave devices),
    • [Performed] to preserve health, diagnose or cure disease, repair injury, correct deformity or defects, prolong life, relieve suffering, or any elective procedure for aesthetic, reconstructive or cosmetic purposes.
  • Procedures that use Monitored Anesthesia Care, Inhalation Anesthetics or Neuroleptanalgesia.

That covers a lot of things. Does the law make any exceptions?

The office-based surgery rules do not apply to these procedures:

  • Procedures that include a drug-induced alteration of consciousness or require anesthesia
    • Put another way, office-based surgery should never include general anesthesia. A different set of regulations apply to general anesthesia.
  • Procedures that use a single oral dose of a sedative or analgesic appropriate for the unsupervised treatment of anxiety or pain
  • Procedures performed by a physician oral and maxillofacial surgeon within the scope of a license to practice dentistry

What does the Louisiana State Board of Medical Examiners (LSBME) say about office-based surgery?

Physicians performing office-based surgery must have hospital privileges and advanced resuscitation skills. Facilities where office-based surgery is performed must have:

  • A code cart and written emergency procedures.
  • A written and annually updated policy and procedure manual.

What kind of records do I need to keep?

Keep a log of each surgery. The log must be available for inspection without notice by the LSBME. Each physician performing office-based surgery must report to the LSBME annually regarding whether or not he or she performs office-based surgery. For more information, click here or contact the LSBME at officebasedsurgeryreport@lsbme.la.gov.

What else do I need to report?

Physicians should report to the LSBME, in writing and within 15 days, any of the following events:

  • An unanticipated transport of the patient from the facility to a hospital emergency department
  • An unplanned readmission to the office-based surgery facility within 72 hours of discharge from the facility
  • An unscheduled hospital admission of the patient within 72 hours of discharge from the facility
  • The death of a patient within 30 days of a procedure at an office-based surgery facility

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