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 firstname.lastname@example.org.
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