Three-Level System Replaces Five-Level System: The new rules consolidate procedures into Level I (no registration), Level II (moderate sedation), and Level III (deep sedation/general anesthesia), eliminating the previous minimal sedation and local anesthesia categories. Propofol use is now automatically classified as Level III.

Mandatory Accreditation: Level II and III offices must now be accredited by a Board-approved entity within one year of performing the first procedure (previously encouraged but not required).

Enhanced Patient Safety Controls:

• Emergency transfer
• Intra-peritoneal and intra-pleural procedures prohibited without prior Board approval
• Patients with solid organ transplants (except kidney) excluded from office-based surgery
• ASA Physical Status Classification ≥4 patients prohibited for Level III
• Frailty scoring tools required for patients 75+
• Patients 85+ prohibited from Level III procedures without Board approval except under emergency circumstances
• LAST (Local Anesthetic Systemic Toxicity) kit now required for tumescent liposuction
• "Registered Physician" and "Physician Office" now formally defined
• "Clinically necessary peritoneal access occurring incidentally to the primary procedure" explicitly permitted
• Quality Assurance Program: Now mandatory (not just encouraged), with annual engagement required and specific review requirements including mortality, complications, emergency transfers, and outcomes.

Peer Review: Partners may no longer provide peer review for each other

Expanded Reporting Requirements:

• Annual comprehensive procedure lists required
• New Level III procedures must be reported within 30 days
• Annual outcome data submission required
• Accreditation status changes must be reported within 5 business days

Registration Changes:

• Registration now applies to both physicians AND physician offices
• Multiple physicians can register under one office
• One physician must be designated as responsible for accuracy and reporting
• Electronic registration required by January 31 annually
• Full compliance required beginning January 1, 2027

• Core Anesthesia Definitions: Minimal sedation, moderate sedation, deep sedation, and general anesthesia definitions remain consistent with ASA standards
• ACLS Requirements: Physicians and at least one assistant must maintain ACLS certification for Level II and III procedures
• Emergency Planning: Requirements for emergency equipment, transfer protocols, and emergency care capabilities remain similar
• Monitoring Equipment Standards: Core monitoring requirements (pulse oximetry, blood pressure, EKG, etc.) unchanged
• Recovery and Discharge Criteria: Standards for post-procedure monitoring and discharge protocols remain consistent
• Exemption for Oral Surgeons: Dentist-physicians performing exclusively dental procedures remain exempt
• Medical Record Requirements: Documentation standards for patient records, informed consent, and procedure notes remain similar
• Infection Control: Compliance with OSHA requirements and sterilization standards continues
• Reporting Timeline for Adverse Events: Still requires reporting within 3-5 business days (some specifics updated but timeline similar)

Immediate/Near-Term Deadlines

March 16, 2026: New rules become effective

Registration Deadlines

January 31 annually: Registration renewal due (electronic submission)

First Registration: Must be completed and approved BEFORE performing any Level II or III procedures

Accreditation Deadlines

One year from first procedure: Physician offices must achieve accreditation by a Board-approved entity

If not accredited within one year, physician must cease performing procedures until accredited

Reporting Deadlines
Within 5 business days:

• Surgical-related deaths (within 30 days of procedure)
• Events requiring CPR
• Wrong site/wrong patient surgery
• Unplanned reoperations (within 30 days)
• Accreditation status changes

Within 30 days: Report performance of any new Level III procedure

By January 31 annually:

• Registration renewal
• Annual outcome data submission
• Comprehensive list of all procedures performed

Compliance Deadline

January 1, 2027: Full compliance with all new rules required
 

• Currently, registration may be completed by submitting this form and emailing it to obs@albme.gov.
• Both physicians and offices must register. 
• Physician offices may register more than one physician. 
• One registered physician must be designated as responsible for accuracy and reporting.
• Annual OBS registration is due by Jan 31 each year and must be completed electronically.
• Registered physicians must promptly report changes in practice location or required information. 

• Adverse Event Reporting Form
• Reporting to the Board is required within 5 business days of the occurance and will include all surgical related deaths that occur within 30 days of the procedure, anesthetic or surgical events requiring CPR, wrong site surgery, wrong patient surgery, and unplanned reoperation related to a prior office-based surgical procedure occuring within 30 days of the procedure. 
• However, planned operations, reoperations for minor complications, and the transfer of a patient to a more acute setting or a hospital as a a result of the physician's findings during the diagnostic portion of a procedure do not need to be reported. 
• Each physician office shall execute agreements with its accrediting or certifying entities requiring the entity to report any suspension, restriction, termination, or adverse accreditation action, the findings of any surveys and complaint or incident investigations, and any data requested by the Board. The registered physician shall be responsible for submitting or causing the accrediting entity to submit annual outcome data to the Board for all procedures performed at a physician office on or before January 31 following renewal of the physician's registration. 
• Each registered physician shall report to the Board annually in writing a comprehensive list of all procedures performed at each location; provided, the registered physician shall report the performance of any new Level III procedure within 30 days of performing the procedure at a physician office. 
• A physician office where more than one registed physician performs office-based surgery may make reports on behalf of the registered physicians. 

Each physician office shall implement a quality assurance program to periodically review the physician office’s procedures and quality of care provided to patients.

A physician office shall engage its quality assurance program not less than annually. The quality assurance program may be administered by the physician office’s accrediting entity.

A registered physician and his or her partners cannot provide peer review for each other.

A quality assurance program shall include, but not be limited to:

• Review of all mortalities;
• Review of the patient selection, appropriateness, and necessity of procedures performed;
• Review of all emergency transfers;
• Review of surgical and anesthetic complications;
• Review of outcomes, including postoperative infections;
• Analysis of patient satisfaction surveys and complaints;
• Identification of undesirable trends, including diagnostic errors, poor outcomes, follow-up of abnormal test results, medication errors, and system problems; and
• Tracking of all deviations from the patient selection and procedure protocols, including identification of the patient, the basis for the deviation, a description of the medical decision-making supporting the deviation, a description of the outcome, and any remedial measures taken.
• Quality assurance program findings shall be documented and incorporated into the physician office’s educational programming, protocols, and planning, as appropriate.
• Each physician shall attest in writing to the Board that a compliant quality assurance program has been implemented prior to performing any office-based surgery. Each physician shall be responsible for producing the plan to the Board upon demand.

Any type of surgery or diagnostic procedure in which pre-operative medications are not required or used other than minimal pre-operative tranquilization/anxiolysis of the patient. There is no anesthesia, or it is a local, topical, appropriate block. No drug-induced alteration of consciousness other than minimal preoperative tranquilization of the patient is permitted and the chances of complication requiring hospitalization are remote.

Level I office based surgical procedures include, but are not limited to, excisions of skin lesions, moles, warts, cysts and lipomas; repair of lacerations or surgery limited to the skin and subcutaneous tissue; incision and drainage of superficial abscesses; limited endoscopies such as proctoscopies; skin biopsies, arthrocentesis, thoracentesis, paracentesis, and endometrial biopsy; insertions of IUD’s and colposcopy; dilation of urethra and cystoscopic procedures; and closed reductions of simple fractures or small joint dislocations.

• Accreditation Association for Ambulatory Health Care (AAAHC)
• American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
• Surgical Review Corporation (SRC)
• The Joint Commission
• The Board can approve other entities. If you are currently accredited by an organization that isn’t on this list, let us know!

Click here for the Statement of the Alabama Board of Medical Examiners on the Final Adoption of Rule 540-X-10.

No. It is not a requirement to request patient specific approval. The request to treat patients age 85 or older may be approved for certain procedures or class of procedures. 

No. It is not a requirement to request patient specific approval.