This presentation covers the issue of Anesthesia, Surgery and Facility Levels and their impact on Office-Based Surgical Suite (OBSS) regulation (by state). The level (most often anesthesia) is the primary determinant of whether the OBSS must be regulated or accredited in the state.

1. Office-Based Surgical Suite (OBSS)
Anesthesia, Surgery and Facility Levels
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.
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3. OBSS: The Issues
• There are at least 97 orthopedic hand-and-wrist procedures,
that lend themselves to an OBSS, WALANT, and the
SOSD=zero. This means there is no additional reimbursement
for overhead for the OBSS.
• All of these would require negotiation for reimbursement
with each carrier when performed in an OBSS.
www.IOECTR.com 3

4. 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 4

5. Levels - Anesthesia, Surgery and Facility
• These levels/Classes are important to know as they are one of the
main criteria for determining whether accreditation or registration
is necessary for your OBSS.
• Each state has different requirements. These are critical to
establishing your OBSS. Questions related to them will very likely be
part of your negotiation and contract.
• The different levels below are related but also separate.
• There are three levels of Anesthesia as outlined by AAAASF
(American Association for Accreditation of Ambulatory Surgery
Facilities) and anesthesia level.
• There are three levels of Surgery. Note that these are separate
from the anesthesia levels above but there will be a positive
correlation (the more complex the surgery the higher likelihood of a
higher level of anesthesia).
• There are three classes of Facility (A, B and C).
www.IOECTR.com 5

6. Anesthesia Levels (1)
• While the information below refers to ASC’s it also applies to
OBSS guidelines. In general, a level 1 anesthesia level does not
require accreditation; but there are exceptions. Always
confirm your state OBSS guidelines.
• AAAASF (American Association for Accreditation of
Ambulatory Surgery Facilities) and anesthesia level.
• Most OBSS utilize Level 1 (local anesthesia) only.
• AAAASF realizes that centers may provide different levels of
services and therefore their requirements are targeted to
three separate classes of service.
www.IOECTR.com 6

7. Anesthesia Levels (2)
The classes are based on the tiered classifications of anesthesia used and are
defined as:
• Level 1: All procedures performed in the facility are under local or topical
anesthesia.
• Level 2: Surgical procedures performed in the facility encompass Class A
type and are performed under intravenous or parenteral sedation,
regional anesthesia, analgesia or dissociative drugs without the use of
endotracheal or laryngeal mask intubation or inhalation general
anesthesia (including nitrous oxide).
• Level 3: Surgical procedures performed in the facility include Class A and B
types with the use of endotracheal or laryngeal mask intubation and/or
inhalation anesthesia, which is administered by an anesthesiologist or a
Certified Registered Nurse Anesthetist.
www.IOECTR.com 7

8. Office Surgery Levels
• Level I Office Surgery includes, but is not limited to minor
procedures such as excision of skin lesions, moles, warts,
cysts, lipomas and repair of lacerations or surgery limited to
the skin and subcutaneous tissue performed under topical or
local anesthesia not involving drug-induced alteration of
consciousness other than minimal pre-operative
tranquilization of the patient. Most of these are considered
“minor surgery” and have a 10-day global period.
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9. Office Surgery Levels
• Level II Office Surgery includes peri-operative medication and
sedation used intravenously, intramuscularly, or rectally, thus
making intra and post-operative monitoring necessary. This
includes any surgery where the patient is placed in a state
that allows the patient to tolerate unpleasant procedures
while maintaining adequate cardiorespiratory function and
the ability to respond purposefully to verbal command and/or
tactile stimulation (i.e., WALANT). Patients whose only
response is reflex withdrawal from a painful stimulus are
sedated to a greater degree than encompassed by this
definition.
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10. Office Surgery Levels
• Level III Office Surgery involves, or reasonably should require,
the use of a general anesthesia or major conduction
anesthesia and pre-operative sedation. This includes, but is
not limited to, the use of intravenous sedation beyond that
defined for Level II office surgery and general anesthesia.
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11. Surgical Facility Classes
• These are based on the level of care rendered. Each facility class has
minimal equipment required on site.
• Class A facility: Provides for minor surgical procedures performed
under topical, local, or regional anesthesia without preoperative
sedation. Excluded are intravenous, spinal, and epidural routes;
these methods are appropriate for Class B and C facilities.
• Class B facility: Provides for minor or major surgical procedures
performed in conjunction with oral, parenteral, or intravenous
sedation or under analgesic or dissociative drugs.
• Class C facility: Provides for major surgical procedures that require
general or regional block anesthesia and support of vital bodily
functions.
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12. Parting Remarks
• Most regulation requirements are predicated on the level of
anesthesia used in the OBSS. Most (but not all) states do not
require accreditation if only local anesthesia is used.
• Rules change often; be sure to confirm your state’s current
requirements for an OBSS.
• Consult with a healthcare attorney.
• Review your mix of zero SOSD codes.
• Don’t underestimate the financial impact of implementing an
OBSS (in regard to SOSD and reimbursement).
• More information on OBSS regulations and guidelines is
available free on www. IOECTR.com
www.IOECTR.com 12

13. 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.
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14. Office-Based Surgical Suite (OBSS)
Anesthesia, Surgery and Facility Levels
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