The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Committee on Fiscal Policy
BILL: CS/CS/SB 1188
INTRODUCER: Fiscal Policy Committee; Health Policy Committee; and Senator Garcia
SUBJECT: Office Surgeries
DATE: February 26, 2024 REVISED:
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Rossitto-Van
Brown HP Fav/CS
Winkle
2. Rossitto-Van
Yeatman FP Fav/CS
Winkle
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/CS/SB 1188 provides office surgery practice standards and additional enforcement authority
to the Department of Health (DOH) over physician offices in which physicians perform certain
liposuction procedures or gluteal fat grafting procedures, also known as Brazilian Butt Lifts
(BBLs).
The bill requires that, in addition to other circumstances that require office surgery registration:
 Physicians register their offices for office surgery with the DOH if they intend to perform
liposuction procedures in their offices in which more than 1,000 cc of supernatant fat is
temporarily or permanently removed. Current law does not specify temporarily or
permanently.
 Physicians register their offices for office surgery with the DOH if they intend to perform
gluteal fat grafting procedures in their offices. Current law does not expressly require
registration for the performance of such procedures by name.
 Physicians register their offices for office surgery with the DOH if they intend to perform
certain liposuction procedures during which the patient is rotated between the supine, lateral,
and prone positions.
The bill:
 Modifies the penalty for performing surgery in an unregistered office, if the surgery requires
office registration, from a fine of $5,000 per day to $5,000 per incident, to allow the DOH to
fine a physician for multiple offenses committed during the same day.
BILL: CS/CS/SB 1188 Page 2
 Authorizes the DOH to utilize a heightened inspection procedures for office surgery
registration and updates and provides detailed directions to the DOH regarding requirements
for physician office surgery inspections and requires applicants to identify in the application
specific personnel and procedures and regularly update that information with the boards.
 Requires that physicians who have registered their offices prior to July 1, 2024, to update
their registration, if a physician performs gluteal fat grafting procedures or certain liposuction
procedures during the office surgery.
 Creates a registration update process with an updated registration inspection at next annual
inspection and provides additional time for compliance with additional requirements and
procedures upon request.
 Requires office surgery applicants to document that the applicant has met the applicable
requirements of s. 469 of the Florida Building Code for office surgery suites if they perform
gluteal fat grafting procedures or certain liposuction procedures.
 Creates new sections of statute for all levels of office surgeries to codify existing rules of the
Board of Medicine (BOM) and Board of Osteopathic Medicine (BOOM).
 Creates additional restrictions on liposuction procedures when performed in combination
with another separate surgical procedure during a single Level II or Level III operation.
 Creates standards for office surgery anesthesia by adopting Standards of the American
Society of Anesthesiologists for Basic Anesthetic Monitoring.
 Authorizes the boards to make rules for additional standards of practice for office procedures
and surgeries as warranted for patient safety and the evolution of technology and practice, to
administer registration and registration update processes, and inspections and safety of office
procedures and surgeries.
 Provides an exemption for physicians who are dually licensed as dentists while such
practitioner is performing dental procedures that are regulated under the practice of dentistry.
The bill takes effect upon becoming law.
II. Present Situation:
Regulation of Office Surgeries
The Board of Medicine (BOM) and the Board of Osteopathic Medicine (BOOM) (collectively,
the boards)1, within the DOH2, have authority to adopt rules to regulate practice of medicine and
osteopathic medicine, respectively. The boards have authority to establish, by rule, standards of
practice for particular settings.3 Such standards may include education and training; medications,
including anesthetics; assistance of and delegation to other personnel; sterilization; performance
of complex or multiple procedures; records; informed consent; and policy and procedures
manuals.4
1
Chapter 458, F.S., regulates the practice of allopathic medicine, and ch. 459, F.S., regulates the practice of osteopathic
medicine.
2
The Dept. of Health, Division of Medical Quality Assurance (MQA), serves as the principle administrative unit for the
Board of Medicine and the Board of Osteopathic Medicine.
3
Sections 458.331(v) and 459.015(z), F.S.
4
Id.
BILL: CS/CS/SB 1188 Page 3
The boards set forth the standards of practice that must be met for office surgeries. An office
surgery is any surgery that is performed outside a facility licensed under ch. 390, F.S., or ch. 395,
F.S.5 There are several levels of office surgeries governed by rules adopted by the boards, which
set forth the scope of each level of office surgeries, the equipment and medications that must be
available, and the training requirements for personnel present during the surgery.
Registration
A physician is required to register his or her office with the DOH to perform liposuction
procedures in which more than 1,000 cubic centimeters of supernatant fat is removed, a level II
office surgery, or a level III office surgery.6
Each registered office must designate a physician who is responsible for complying with all laws
and regulations establishing safety requirements for such offices.7 The designated physician is
required to notify the DOH within 10 days of hiring any new recovery or surgical team
personnel.8 The office must notify the DOH within 10 calendar days after the termination of a
designated physician relationship.9
The DOH must inspect any office where office surgeries will be done before the office is
registered.10 If the office refuses such inspection, it will not be registered until the inspection can
be completed. If an office that has already been registered with the DOH refuses inspection, its
registration will be immediately suspended and remain suspended until the inspection is
completed, and the office must close for 14 days.11
The DOH must inspect each registered office annually unless the office is accredited by a
nationally recognized accrediting agency approved by the respective board. Such inspections
may be unannounced.12
The DOH’s license verification web page indicates there are 1,816 office surgery registrations.13
Standards of Practice
Prior to performing any surgery, a physician must evaluate the risks of anesthesia and the
surgical procedure to be performed.14 A physician must maintain a complete record of each
surgical procedure, including the anesthesia record, if applicable, and written informed consent.15
5
Fla. Admin. Code Rs. 64B8-9.009(1)(d) and 64B15-14.007(1)(d), (2023). Abortion clinics are licensed under ch. 390, F.S.,
and facilities licensed under ch. 395, F.S., include hospitals, ambulatory surgery centers, mobile surgical facilities, and
certain intensive residential treatment programs.
6
Sections 458.328(1) and 459.0138(1), F.S.
7
Fla Admin. Code Rs. 64B8-9.0091(1) and 64B15-14.0076(1), (2023).
8
Id.
9
Id.
10
Supra note 5.
11
Id.
12
Id.
13
Florida Agency for Health Care Administration, House Bill 1561, 2024 Agency Legislative Bill Analysis (Jan. 18, 2024)
(on file with the Senate Committee on Health Policy).
14
Fla. Admin. Code Rs. 64B8-9.009(2) and 64B15-14.007(2), (2023).
15
Id. A physician does not need to obtain written informed consent for minor Level I procedures limited to the skin and
mucosa.
BILL: CS/CS/SB 1188 Page 4
The written consent must reflect the patient’s knowledge of identified risks, consent to the
procedure, type of anesthesia and anesthesia provider, and that a choice of anesthesia provider
exists.16
Physicians performing office surgeries must maintain a log of all liposuction procedures in
which more than 1,000 cubic centimeters of supernatant fat is removed and Level II and Level
III surgical procedures performed, which includes:17
 A confidential patient identifier;
 The time the patient arrives in the operating suite;
 The name of the physician who provided medical clearance;
 The surgeon’s name;
 The diagnosis;
 The CPT codes for the procedures performed;
 The patient’s ASA classification;
 The type of procedure performed;
 The level of surgery;
 The anesthesia provider;
 The type of anesthesia used;
 The duration of the procedure;
 The type of post-operative care;
 The duration of recovery;
 The disposition of the patient upon discharge;
 A list of medications used during surgery and recovery; and
 Any adverse incidents.
Such logs must be maintained for at least six years from the last patient contact and must be
provided to the DOH investigators upon request.18
For elective cosmetic and plastic surgery procedures performed in a physician’s office:19
 The maximum planned duration of all planned procedures cannot exceed eight hours.
 A physician must discharge the patient within 24 hours, and overnight stay may not exceed
23 hours and 59 minutes.
 The overnight stay is strictly limited to the physician’s office.
 If the patient has not sufficiently recovered to be safely discharged within the 24-hour period,
the patient must be transferred to a hospital for continued post-operative care.
Office surgeries are prohibited from:
 Resulting in blood loss greater than ten percent of blood volume in a patient with normal
hemoglobin;
16
Id. A patient may use an anesthesiologist, anesthesiologist assistant, another appropriately trained physician, certified
registered nurse anesthetist, or physician assistant.
17
Fla. Admin. Code Rs. 64B8-9.009(2)(a) and 64B15-14.007(2)(a), (2023).
18
Id.
19
Fla. Admin. Code Rs. 64B8-9.009(2)(f) and 64B15-14.007(2)(f), (2023).
BILL: CS/CS/SB 1188 Page 5
 Requiring major or prolonged intracranial, intrathoracic, abdominal, or joint replacement
procedures, excluding laparoscopy;
 Involving a major blood vessel with direct visualization by open exposure of the vessel, not
including percutaneous endovascular treatment20; or
 Being emergent or life threatening.
Levels of Office Surgeries
Level I
Level I involves the most minor of surgeries, which require minimal sedation21 or local or topical
anesthesia, and have a remote chance of complications requiring hospitalization.22 Level I
procedures include:23
 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;
 Liposuction involving the removal of less than 4,000 cc supernatant fat; and
 Incision and drainage of superficial abscesses, limited endoscopies such as proctoscopies,
skin biopsies, arthrocentesis, thoracentesis, paracentesis, dilation of urethra, cryptoscopic
procedures, and closed reduction of simple fractures or small joint dislocations (e.g., finger
and toe joints).
Level II
Level II office surgeries involve moderate sedation24 and require the physician office to have a
transfer agreement with a licensed hospital that is no more than 30 minutes from the office.25
Level II office surgeries, include but are not limited to:26
 Hemorrhoidectomy, hernia repair, large joint dislocations, colonoscopy, and liposuction
involving the removal of up to 4,000 cc supernatant fat; and
 Any surgery in which the patient’s level of sedation is that of moderate sedation and
analgesia or conscious sedation.
A physician performing a Level II office surgery must:27
20
Such treatment addresses conditions such as peripheral artery disease and other arterial blockages.
21
Minimal sedation is a drug-induced state during which the patient responds normally to verbal commands. Although
cognitive function and physical coordination may be impaired, airway reflexes, and ventilator and cardiovascular functions
are not impaired. Controlled substances are limited to oral administration in doses appropriate for the unsupervised treatment
of insomnia, anxiety, or pain.
22
Fla. Admin. Code Rs. 64B8-9.009(3) and 64B15-14.007(3), (2023).
23
Id.
24
Moderate sedation or conscious sedation is a drug-induced depression of consciousness during which a patient responds
purposefully to verbal commands, either alone or accompanied by light tactile stimulations. No interventions are needed to
manage the patient’s airway and spontaneous ventilation is adequate. Cardiovascular function is maintained. Reflex
withdrawal from a painful stimulus is not considered a purposeful response.
25
Fla. Admin. Code Rs. 64B8-9.009(4) and 64B15-14.007(4), (2023).
26
Id.
27
Id.
BILL: CS/CS/SB 1188 Page 6
 Have staff privileges at a licensed hospital to perform the same procedure in that hospital as
the surgery being performed in the office setting;
 Demonstrate to the appropriate board that he or she has successfully completed training
directly related to and include the procedure being performed, such as board certification or
eligibility to become board-certified; or
 Demonstrate comparable background, training, or experience.
A physician, or a facility where the procedure is being performed, must have a transfer
agreement with a licensed hospital within a reasonable proximity28 if the physician performing
the procedure does not have staff privileges to perform the same procedure at a licensed hospital
within a reasonable proximity.
Anesthesiology must be performed by an anesthesiologist, a certified registered nurse anesthetist
(CRNA), or a qualified physician assistant (PA). An appropriately-trained physician, PA, or
registered nurse with experience in post-anesthesia care, must be available to monitor the patient
in the recovery room until the patient is recovered from anesthesia.29
Level IIA
Level IIA office surgeries are those Level II surgeries with a maximum planned duration of five
minutes or less and in which chances of complications requiring hospitalization are remote.30 A
physician, physician assistant, registered nurse, or licensed practical nurse must assist the
surgeon during the procedure and monitor the patient in the recovery room until the patient is
recovered from anesthesia.31 The assisting health care practitioner must be appropriately certified
in advanced cardiac life support, or in the case of pediatric patients, pediatric advanced life
support.32
Level III
Level III office surgeries are the most complex and require deep sedation or general anesthesia. 33
A physician performing the surgery must have staff privileges to perform the same procedure in
a hospital.34 The physician must also have knowledge of the principles of general anesthesia.
28
Transport time to the hospital must be 30 minutes of less.
29
Id. The assisting practitioner must be trained in advanced cardiovascular life support, or for pediatric patients, pediatric
advanced life support.
30