To the Editor:

I’m writing to give another viewpoint on the topic of in-office surgery, not just for cataracts but for other procedures such as, in my case, oculofacial plastics.

I’ve been doing in-office plastics procedures for five years here in my Coral Gables office. I decided to write because CMS’s focus has been on cataracts, but I’d like my colleagues to know that in-office can also apply to other procedures. Before opening my surgical suite, I contracted with a firm called Total Medical Consultants to guide me through the requirements, specs and structure that needed to be in place so the Florida Medical Board would accredit my facility as a certified office surgical suite. I understand that in some states there is no overseeing association/board to make sure that these in-office surgical suites are up to code. However, in my state there is, and I get inspected yearly to ensure I’m compliant.

The list of requirements doesn’t fall short of those of an ASC facility, which I know about, as I’m also a minority owner of an ASC. These include proper documentation, mandatory use of RN’s, appropriate physical layout of the surgical suite, backup battery power, crash cart, etc. We’re also required to do quarterly risk management meetings headed up by Total Medical Consultants. My experience has been great, with no infections or complications in five years, doing hundreds of cases per year. The suite can be certified to do up to Level-III anesthesia.

In terms of the big question—reimbursement—as we know, there is no “in-office facility” code. However, third-party payers, including Medicare, will pay a bit more for procedures done in a non-facility setting, though this obviously doesn’t cover the overhead costs of the procedure. There are some HMO’s here in Miami that have realized the potential cost savings and have been willing to pay the physician for the use of his in-office facility, but have been unable to, as they too follow CMS guidelines. The biggest advantage at this time for me to do in-office surgery has been being more efficient with time (i.e., seeing new consults between cases, taking care of paperwork), which I wouldn’t have been able to do if I were away. Also, it allows me to capture the cosmetic market because I can offer lower facility fees than hospitals and ASCs.

I use an anesthesiologist to give the sedation, as I feel it’s safer and more comfortable for the patient. Also, in case of an emergency, an anesthesiologist’s experience is superior to a nurse anesthetist’s, and this removes the primary liability for anesthesia and airway issues from the surgeon. This is an important point: When you use a nurse anesthetist, you are 100-percent responsible for all the drugs he administers, and for any issues that may arise from anesthesia.

 I hope this letter sheds some light on in-office surgery, and that CMS creates an in-office facility fee code in the near future.  

Joseph Selem, MD
Coral Gables, Fla.