Additional Practice Topics for Physicians

There are 2 types of physicians who need to register for Office Based Anesthesia:

• A physician who provides level II-IV anesthesia services in an outpatient setting (including analgesics and anxiolytics).
• A physician who performs a procedure for which level II-IV anesthesia services are provided in an outpatient setting (including analgesics and anxiolytics).

OBA registration does not apply to physicians who practice in the following settings:

• An outpatient setting in which only local anesthesia, peripheral nerve blocks, or both are used.
• Any setting physically located outside the State of Texas.
• A licensed hospital, including an outpatient facility of the hospital that is located apart from the hospital.
• A licensed ambulatory surgical center.
• A clinic located on land recognized as tribal land by the federal government and maintained or operated by a federally recognized Indian tribe or tribal organization as listed by the United States secretary of the interior under 25 U.S.C. (479-1) or as listed under a successor federal statute or regulation.
• A facility maintained or operated by a state or governmental entity.
• A clinic directly maintained or operated by the United States or by any of its departments, officers, or agencies.
• An outpatient setting accredited by:
  • The Joint Commission on Accreditation of Healthcare Organizations relating to ambulatory surgical centers;
  • The American Association for the Accreditation of Ambulatory Surgery Facilities; or
  • The Accreditation Association for Ambulatory Health Care.
• The performance of Mohs micrographic surgery.
• Provide only level I services.

Note: physicians that provide only level I services, must still meet all other requirements under Chapter 173.

In addition to the general standards that apply to all outpatient settings, the following standards are required for outpatient settings, based upon the level of anesthesia being administered. If personnel and equipment meet the requirements of a higher-level, lower-level anesthesia services may also be provided.  See Board rule 173.2 for minimum equipment requirements and standards.

Level I services - Delivery of narcotic analgesics or anxiolytics by mouth, as prescribed for the patient on order of a physician, at a dose level not to exceed minimal sedation, as defined under Board rule, or delivery of nitrous oxide/oxygen inhalation sedation. 

• A physician and at least two personnel must be present, including the physician who must be currently certified by AHA or ASHI, at a minimum, in BLS; and
• The following age-appropriate equipment must be present:
  • Bag mask valve; and
  • Oxygen.

Level II services -  The administration of tumescent anesthesia; the delivery of tumescent anesthesia in conjunction with the delivery of narcotic analgesics or anxiolytics by mouth in dosages as defined under Level I, as prescribed for the patient on order of a physician; or except for the performance of Mohs micrographic surgery, the administration of local anesthesia, peripheral nerve blocks, or both in a total dosage amount that exceeds 50 percent of the recommended maximum safe dosage per outpatient visit. 

• A physician and at least one other personnel must be present during the procedure and recovery until ready for discharge. The physician must be currently certified by AHA, ASHI, or ASA in ACLS, PALS, or PeRLS as appropriate. The additional personnel member(s) must be currently certified by AHA or ASHI, at a minimum in BLS.
• A crash cart must be present containing drugs and equipment necessary to carry out ACLS protocols, including, but not limited to:
  • The age-appropriate monitoring and emergency equipment required under in Board rule 173.2;
  • First line cardiac medications, including epinephrine, atropine, adreno-corticoids, and antihistamines;
  • Benzodiazepines for intravenous or intramuscular administration;
  • Lipid emulsion to treat local anesthetic systemic toxicity, if administering local anesthesia, peripheral nerve blocks, or both in a total dosage amount that exceeds 50 percent of the recommended maximum safe dosage per outpatient visit (except for Mohs micrographic surgery), or if administering tumescent anesthesia; and
  • Specific reversal agents, Flumazenil and Naloxone, if benzodiazepines or narcotics are used for sedation.

Level III services - Intravenous, intramuscular, mucosal, rectal or inhalational delivery of narcotic analgesics, anxiolytics, or hypnotics to achieve moderate sedation, as defined in Board rule. Level III services do not include deep sedation or general anesthesia.

• A physician and at least one other personnel must be present during the procedure and recovery until ready for discharge. The physician must be currently certified by AHA, ASHI, or ASA in ACLS or PALS, or PeRLs as appropriate. The additional personnel member(s) must be currently certified by AHA, ASHI, or ASA in ACLS, PALS, or PeRLS, as appropriate.
• A crash cart must be present containing the same drugs and equipment required for Level II, and a backup cylinder of oxygen, except for lipid emulsion.
• Intravenous access must be established.
• Providers must adhere to ASA Standards for Post Anesthesia Care.

Level IV services - The use of regional or neuraxial anesthesia and/or the use of anxiolytics, narcotic analgesics, and/or hypnotics to establish deep sedation or general anesthesia, as defined under this Chapter.

Level IV services do not require physicians to maintain a stock of lipid emulsion.  Physicians who practice medicine in Texas and who administer anesthesia or perform a procedure for which anesthesia services are provided in outpatient settings at Level IV shall follow current, applicable standards and guidelines as put forth by the American Society of Anesthesiologists (ASA) including, but not limited to, the following:

• Basic Standards for Pre-anesthesia Care;
• Standards for Basic Anesthetic Monitoring;
• Standards for Post-anesthesia Care;
• Position on Monitored Anesthesia Care;
• The ASA Physical Status Classification System;
• Guidelines for Non-operating Room Anesthetizing Locations;
• Guidelines for Ambulatory Anesthesia and Surgery; and
• Guidelines for Office-Based Anesthesia; and
• Practice sites shall maintain a separate oxygen cylinder as a secondary supply.

Physicians or surgeons must notify the board in writing within 15 days if a procedure performed in any of the settings under these rules resulted in an unanticipated and unplanned transport of the patient to a hospital for observation or treatment for a period in excess of 24 hours, or a patient's death intraoperatively or within the immediate postoperative period. Immediate postoperative period is defined as 72 hours.  Please use the form below for notification of unanticipated transfer/hospitalization or death.

Unanticipated Transfer/Hospitalization or Death

Please contact the Registration Department at Registrations@tmb.state.tx.us if you have any additional questions.

At this time a physician may not hold the position of off-line medical director for more than 20 EMS providers unless the physician obtains a waiver.

The TMB may grant a waiver to allow a physician to serve as an off-line medical director for more than 20 EMS providers, if the physician provides evidence that:

• The Department of State Health Services has reviewed the waiver request and has determined that the waiver in the best interest of the public;
• The physician is in compliance with Board rule, by submitting documentation of protocols and standing orders upon request; and
• Appropriate safeguards exist for patient care and adequate supervision of all EMS personnel under the physician's supervision.

To request a waiver to hold the position of off-line medical director for more than 20 EMS providers, please submit a completed EMS Waiver Request Form for each individual EMS provider you need a waiver for.

If you have any questions, please email the Registration Department

For each EMS medical director there are additional continuing education requirements.

Per Board rule 169.12 each EMS off-line medical director is required to meet the following requirements:

• Within two years, either before or after initial notification to the board of holding the position as off-line medical director:
  • 12 hours of formal continuing medical education (CME) in the area of EMS medical direction;
  • Board certification in Emergency Medical Services by the American Board of Medical Specialties or a Certificate of Added Qualification in EMS by the American Osteopathic Association Bureau of Osteopathic Specialists; or
  • A DSHS approved EMS medical director course; and
• Every two years after meeting the above requirements, one hour of formal CME in the area of EMS medical direction.

Please see Board rule 169, available on our website for a complete listed of EMS off-line medical director requirements.

The physician shall provide notice to patients of when the physician intends to terminate the practice, retire or relocate, and will no longer be available to patients, and offer patients the opportunity to obtain a copy of their medical records or have their records transferred.

Notification shall be accomplished by:

• Letter or email to each patient seen in the last two years by the departing physician; and
• Posting a notice in a conspicuous location in the physician's/practice office and on the practice website at least 30 days prior to the termination, leaving, or sale or relocation of practice.

Board rule 163.5 states that a custodian of records is as follows:

• In case of physician death - the administrator, executor of the estate, or other court appointed individual, unless part of a group practice or pre-existing appointments/instructions are in place;
• In case of physician mental or physical incapacity - individual with Power of Attorney, court appointed individual, or legally appointed representative of the physician;
• Ather circumstances or abandonment of records - custodian is determined on a case-by-case basis.

 A records custodian must:

• Maintain the confidentiality of the medical records;
• Within 30 days of appointment, provide notice of the custodianship of the records to the board and patients by:
  • Posting visible notice in physician's/practice office, if accessible;
  • Posting notice on a physician or practice website, if accessible; or
  • Posting notice in a newspaper of greatest general circulation in county where physician Practice was located.
• Retain the medical records in accordance with state and federal law for at least 90 days before destroying any records, including the 30-day notice period;
• Include the following information in the notice:
  • The name of custodian and contact information;
  • Instructions as to how patients can obtain or request transfer of medical records to another provider;
  • All applicable fees to be charged for the records, in accordance with this chapter, including an additional $25.00 custodial fee as applicable; and
  • A statement that the records may be destroyed after 90 days and provide destruction date.

The Custodian of Records Form is available to assist with the submission of this information to the board.

A physician is not required to provide notice of his or her discontinuation of practice to patients if the physician:

• Treated the patient while in a locum tenens position at a practice location for a period of no longer than six months at that location. For the purpose of this section, "locum tenens" is defined as a position in which a physician is employed or contracted on a temporary or substitute basis to provide physician services; or
• Only treated the patient in the following settings:
  • A hospital, as defined under Texas Occupations Code Section 157.051(6);
  • An emergency room;
  • A birthing center; or
  • An ambulatory surgery center; or
• Only provided the following:
  • Anesthesia services; or
  • Radiology services; or
  • Pathology services.