top of page

Accreditation Requirements For Office Based Surgery

Although the precise definition varies from state-to-state, an Office Based Surgery Facility or Office Based Surgery Medical Practice (an OBSF or OBS for short) is a customized medical office where surgical or diagnostic procedures are performed that involve invasive or subcutaneous penetration.  Most jurisdictions classify procedures as “surgical” or “invasive” by reference to the type and level of sedation or anesthesia used. 


Accordingly, an OBS medical practice can be located in any structure or suite of rooms established by one or more physicians for the private practice of medicine, but is typically limited to one surgical operating room. 


Twenty-six state health departments, including Delaware and Pennsylvania, have jurisdiction on office-based surgery meeting various thresholds. The most common specialties performing office-based surgery are pain management, plastic surgery and GI. The requirement is typically based on the levels of anesthesia used and/or complexity of procedure performed. 





In Delaware and Pennsylvania an OBS medical practice is exempt from licensure requirements that apply to other surgical centers, such as hospitals or ambulatory surgical centers (ASCs).  Unlike these larger institutional surgical facilities, OBS practices do not have to satisfy the more stringent physical plant, safety and sanitary requirements imposed on the licensed facilities.


However, Delaware and Pennsylvania State law requires a practice performing office-based surgery to register with the Office of Health Facilities Licensing and Certification (OHFLC).  In addition, both also require certification of the office-based medical practice location where the surgery takes place by an approved accrediting agency. These agencies include the following:


  • The Joint Commission (TJC)

  • Accreditation Association for Ambulatory Health Care (AAAHC)

  • Healthcare Facilities Accreditation Program (HFAP)

  • American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)

An Office Based Surgery Medical Practice is an integrated part of a medical practice. All billing is done through the EIN of the medical practice and, accordingly, the ownership of the OBSF is the same as that of the medical practice.

An OBS practice cannot bill a separate facility fee for procedures performed although the professional fee that is billed and reimbursed for the office-based surgery procedure is often at a significantly higher level that would otherwise be paid by a payor.

The ultimate certification of a medical practice location as an OBS involves a spectrum of requirements that are determined by each of the above listed accreditation agencies. Each agency has different requirements and, although some overlap, most accreditation agencies requirements focus on different types of facilities.  Accordingly, since any one of the listed agencies is acceptable, it is important to select the accreditation agency that is most appropriate for the type of facility seeking to obtain the certification.

Accreditation typically involves an inspection of the location by the accreditation agency and a review of the following areas:

I. Policies and Procedures – Specific manuals and procedure requirements exist for each accrediting agency.


II. Implementation and Staff Training  - A review of the training that the practice staff has received on the various policies and procedures mentioned in item 1.


III. Physical Plant Requirements – There are specific requirements regarding the layout of the facility as well as location of various required equipment and supplies. 


IV. Observation of Actual Procedures – Typically every accreditation agency will supervise actual procedures performed at the facility to assure adherence to all items from steps 1 – 3 above.


For any practice that falls under the requirements of an OBS but has not yet been accredited, Northeast Management Consulting can perform a survey of the facility and provide an OBS Accreditation Evaluation Report in order to help it assess its readiness for obtaining certification as an office-based surgery medical practice as required by the State of Delaware and the Commonwealth of Pennsylvania. 

This evaluation includes the following:


  • A walk-through of the Facility’s Office

  • A review of the surgical and diagnostic procedures currently being performed at the Facility.

  • An evaluation of the current policies and procedures, staffing, supplies, equipment and physician plant at the Facility.

  • Based upon the type of procedures and status of the physician location, a determination of the appropriate accreditation agency to utilize for certification.

  • This preparation of an Evaluation Report documenting any potential shortcomings regarding certification and recommendation of either moving forward with certification or other alternatives.

  • An example of a report can be seen here.

An example of a report can be seen here.

If a practice is performing procedures without an accreditation they should ascertain if they could qualify for accreditation and, if so, should apply for accreditation immediately.  The typical time frame for accreditation can be up to four months, however, an expedited process is available from certain of the agencies.

If you are a practice located in Delaware or Pennsylvania and would like additional information please contact our Philadelphia offices at 215.659.3151 and ask for our lead compliance consultant, Jeff Koch. He will be happy to discuss how we can help you in obtaining accreditation. All inquiries are confidential. 

bottom of page