This presentation is an introduction to WALANT and the reimbursement issues related to WALANT procedures and the Office-Based Surgical Suite (OBSS). I am not a clinician, I am a reimbursement expert so this focuses on the business issues.

1. Office-Based Surgery and WALANT
June 5 2021
Jeffrey Restuccio, CPC, COC, MBA
Certified medical coder, auditor, and reimbursement consultant
http://www.IOECTR.com
ritecode@gmail.com
(901) 517-1705

2. OBSS: The Issues
• Numerous surgical procedures can now be safely performed in an
Office-Based Surgical Suite (OBSS) instead of an ASC, HOPD or
hospital. The more common acronym is OBS (Office-Based Surgery)
• Many procedures take only about ten minutes and lend themselves
to: WALANT: Wide Awake Local Anesthesia with No Tourniquet.
• The issue is that many surgical procedures have a status indicator of
"NA" in the “Non-Facility NA INDICATOR” field in the 2021 Medicare
PFSRVU database. This means there is no additional
reimbursement for the OBSS. The Site-of-Service Differential
(SOSD) is zero.
• At least 97 orthopedic hand-and-wrist procedures have a zero
SOSD and lend themselves to an WALANT and OBSS.
www.IOECTR.com 2

3. Acronym Explanations
OBSS: Office-Based Surgical Suite. This means not at a facility (ASC,
HOPD, or hospital) and the Place of Service = 11.
OBS: Office-Based Surgery
IOECTR: In-Office Endoscopic Carpal Tunnel Release. This describes
Endoscopic Carpal Tunnel Release performed in an OBSS, typically
under WALANT.
WALANT: Wide Awake Local Anesthesia with No Tourniquet. This is
not a specific code but a new way to perform many hand and wrist
surgeries under local anesthesia.
SOSD: Site-of-Service Differential. This is the difference in
reimbursement for a procedure when performed in an office
(typically higher) versus a facility. Many procedures have zero SOSD.
www.IOECTR.com 3

4. What is WALANT? (1)
• Many hand surgery procedures such as carpal tunnel release,
tendon repair and removal of masses can now be performed under
local anesthesia alone, avoiding the use of sedation or general
anesthesia. The technique—known as Wide-Awake Local
Anesthesia, No Tourniquet (WALANT)—can be performed in the
surgeon's office.
• The ability to safely control bleeding and extend the duration of
local anesthesia allows hand surgeons to perform many procedures
with minimal bleeding and without the use of sedation, general
anesthesia or a painful tourniquet to control bleeding.
• WALANT also can be used safely in patients who have medical
complications or take blood thinner medications—factors that
might otherwise preclude surgery.
www.IOECTR.com 4

5. What is WALANT? (2)
• While WALANT can be performed in an Ambulatory Surgery Center,
it is often performed in the office and therefore considered an
Office-Based-Surgery (OBS).
• Hand surgery has traditionally been performed under anesthesia
due to the common use of a tourniquet. While the tourniquet
prevents blood flow to the limb in order to achieve a bloodless
operative procedure, it is particularly painful for an awake patient.
• In this revolutionary procedure, the tourniquet has been replaced
by two medications in order to avoid anesthesia. These medications
are lidocaine (to block pain), epinephrine (to stop bleeding – a task
formerly achieved with the tourniquet) and sodium bicarbonate (to
buffer the solution to make it nearly painless).
www.IOECTR.com 5

6. WALANT RESEARCH
• There are numerous of peer-reviewed papers detailing the safety of
the WALANT approach. The first papers appeared over 15 years ago
by Dr. Don LaLonde, based in Canada. A more complete list is on the
website, in the Guidebook and in a separate presentation.
• 1. Lalonde, D, Bell, M, Benoit, P. A multicenter prospective study of
3,110 consecutive cases of elective epinephrine use in the fingers and
hand: the dalhousie project clinical phase. J Hand Surg 2005; 30(5): 1061–
1067.
• 2. Van Demark RE, Becker HA, Anderson MC, Smith VJS. Wide-Awake
Anesthesia in the In-Office Procedure Room: Lessons Learned. HAND.
2018;13(4):481-485. doi:10.1177/1558944717715120
• 3. C.J. Thomson, D.H. Lalonde, K.A. Denkler, A.J. Feicht, A critical look at
the evidence for and against elective epinephrine use in the finger, Plast
Reconstr Surg, 119 (1) (2007), pp. 260-266
www.IOECTR.com 6

7. ASC OR OBSS?
• WALANT procedures can be performed in either the ASC or
OBSS. The specific clinical benefits of local anesthesia are the
same regardless of the Place of Service.
• Establishing an OBSS is mostly a matter of convenience for the
surgeon and the patient.
• While some procedures (e.g., in cardiology) have high SOSD
and pay significantly more when performed in the office
(NON-FAC PE), many surgical procedures have zero SOSD and
are considered “facility-only.”
• They key to financial success is negotiating a carve-out (for
overhead) for all your OBSS procedures with zero SOSD with
each carrier.
www.IOECTR.com 7

8. Parting Remarks
• WALANT can be performed in the OBSS or ASC.
• We have a separate presentation on the benefits of WALANT,
THE OBSS and ECTR.
• When setting up an OBSS always consult with a healthcare
attorney.
• Review your mix of zero SOSD codes and those that lend
themselves to WALANT.
• Don’t forget the financial impact of implementing an OBSS (in
regard to SOSD and reimbursement).
• All SOSD=zero procedures would require negotiation for
reimbursement with each carrier when performed in an OBSS.
• More information is available on www. IOECTR.com
www.IOECTR.com 8

9. Hold Harmless Statement
• This coding and reimbursement information is provided for
educational purposes only.
• It is not intended to represent the only, or necessarily the best,
coding advice for the situations discussed, but rather represents an
approach, view, statement, or opinion that may be helpful to
persons responsible for coding and billing in a medical clinic.
• The statements made in this presentation should not be construed
as policy or procedure, nor as standards of care. State requirements
and policies change all the time; while every effort was made to
ensure accuracy, the author makes no representations and/or
warranties, express or implied, regarding the accuracy of the
information contained in this presentation and disclaims any liability
or responsibility for any consequences resulting from or otherwise
related to any use of, or reliance on this information.
www.IOECTR.com 9

10. Office-Based Surgery and WALANT
June 5 2021
Jeffrey Restuccio, CPC, COC, MBA
Certified medical coder, auditor, and reimbursement consultant
http://www.IOECTR.com
ritecode@gmail.com
(901) 517-1705