Republic of he PHILIPPINE HEALTH INSURANCE CORPORATION Ctystate Centre, 709 Shaw Boulevard, Pasig City (Call eter (02)441-7442 Trunkline (02) 441-7448 ‘ ‘wunwphilhsalth.gov.ph 2 i 3 PHILSEALTH CIRCULAR No. 26ilo - 001+ ALL PHILHEALTH MEMBERS, ACCREDITED HEALTH To : CARE PROVIDERS (HCPs), PHILHEALTH REGIONAL OFFICES (PROs), AND ALL OTHERS CONCERNED SUBJECT : | ANNEX2~LIST OF PROCEDURE CASE RATES (REVISION 3.0) AND SUPPLEMENTARY GUIDELINES FOR ALL CASE RATES 1, RATIONALE ‘As per Rule I, Sections 35 (objective) and 36 (Functions) of the revised IRR of RA 7875 as amended by RA 9241 and 10606, “the National Health Insurance Program aims to provide its members with responsive benefit packages. In view of this, the Corporation shall continuously endeavor to improve its benefit package to meet the needs of its members.” In stting certain provcions in the policy, the concerned specialty societies and other stakebolders have been consulted. This and future enbaneements of All Case Rates policies ret the diversified sopes of profesional practice and prevailing clinical seting, I, SCOPE ‘This Circular shall cover the following revisions for selected procedures listed in Annex 2 — List of Procedure Case Rates Revision 2.0): A. Relative Value Scale (RVS) codes/ procedures with changes in case rate amount and /or conditions for claiming. Delisting of RVS codes/procedures RVS codes/ procedures that shall be claimed only once in a lifetime per eye Reimbursement policy for RVS codes 66820 and 66821 RVS codes/procedures exempted from the 90 day single period of confinement rule Other supplementary guidelines 1. Reimbursement of ophthalmic surgical and laser procedures 2. Intraocular lens (OL) 3. Cataract Pre-surgery Authorization (CPSA) limit mE DOS GUIDELINES The selected procedures listed hetein shall now be used for reference by accredited health care providers and PhilHicalth members/dependents in claiming for PhilHealth reimbursements. Page tot EE veanphieats — GE wwwvfaebookcomPhitealh — YolD warn youtubeconvteamphitheals Kf actoncenter@philesth gov ph+ A. RVS codes/procedures with changes in case rate amount and /or conditions for claiming. (New) ] Health Care 7 RVS code Description First | Institution | P*ofessional Case Rate fee ad Destruction by any method, including dase, w/ or 2/0 surgical curetement, 2 benign facia! lion or premalignant 17000 | desions in any location, or benign kesions 6,000 3,800 2,200 other than vasalar proliferative lesions, including lcal anesthesia; any number of lesions ‘Destruction of cutaneous vascular t7t0g _ | Proliferative lesions (eg, laser 6,000 3,800 2,200 technique) “Reswoval of foreign body, external je; 65205 conjunctival, superficial 500 (300 200 Cornea! relaxing incision for correction of 65772 ically induced astignnais 10,000 6,000 4,000 1. RVS code 17000 shall only be claimed relative fo these conditions: “Maximum | Interval Can only ICD 16 Description/ | Number of | in between be performed Code ‘Diagnosis | sessions per | procedures by patient Verrca vudgaris (located on the Boy palras and soles 6 30 days Diplomate/ Fellow] ‘and periangnal Consultant of Philippine arcas) Dermatological Society (PDS) D220 D221 Newus of Ota 6 90 days 2. RVS code 17106 shall only be claimed relative to the following conditions: Maximum | Interval Can only be IcD 10 Description/ Number of | inbetween | performed by Code Diagnosis sessions per | procedures patient Verrncawigars (lanar or BO7 Z 6 30 periungual) dos Diplomate/ Fellow/ L719 | Resaea (ioe) 6 30dgs | nelowl Hemangioma, any ste ine D18.0 Venous malformation Dermatolog Angioma NOS 7 30days | Society (PDS) sept Cm eg Congenital non-neoplastic 82.5 | mcvas (portwine) op 6 30 days Page 20F8 EE eumphiicakn — wowinectockconsPhticath — YoiED worwoutute.comeanpiteath i. aconcener@pilealgor.ph+ 3, RVS code 65205 (Removal of foreign body, external eye; conjunctival, superficial) can be performed by all acredited physicians, Tbe operative record (with OR technique) sball be attached to tbe clinical chart for monitoring prrpases. Farther, RVS codes 67400, 67405, 67412, 67413, 67414, 67415, 67420, 67430, 67440 and 67445 (exploration, excision and decompression of obit) shall be reimbursed if performed by accredited specialists for trauma and maxillofacial surgery. B. Delisting of RVS codes The following procedures are temporarily delisted until further notice as recommended by the medical specially societies concerned. Hence, claims for these procedures shall be dened. RVS Code Description Destruction by any method inclading laser of benign skin lesions other than 17109 | “tAneous vascular proliferative lesions on any area other than the face, including local anesthesia; any number of lesions 77200 __| Flectrosurgical destruction of multiple fibrocutancous tags; All lesions ating or curettement of benign hyperkeratotic skin lesion w/ or w/o chemical 11050 | cauterization (such as verrucae ot clavi) not extending through the stratum comeum (eg,, callus or wart) w/ or w/o local anesthesia; single lesion ‘Paring oc curettement of benign hyperkeratotic skin lesion w/ or w/o chemical 11051 | cautesization (such as verrucae or clavi) not extending through the stratum comeum (eg, callus or wart) w/ ot w/o local anesthesia; two to four lesions Paring oF curettement of benign hyperkeratotic skin lesion w/ ot w/o chemical 41052__| Sttesization (such as verrucae or clavi) not extending through the stratum. comeum (eg, callus or wart) w/ of w/o local anesthesia; more than four lesions 50205 | Renal bipays by surecal exposure of ida 5420 | Excision or transposition of pleryivm; without graft ‘65771 | Radial keratotomy 67042 | Vitrecamy, mechanical pars plana approach; with radial opts nerve neurotanyy (RON). 7043 | Vitrctomy, mechanical, pars plana approach; with shethotony fr branch retinal vein edison 700g | Vitrctony, neanicah pars Plana approach; with macilar translocation (hited by retinotony and or scleral inbrication) 67045 | Vitrectam, mechanical pars plana approach; with racular ransheation (total) C. RVS codes/ procedures that shall be claimed only once in a lifetime per eye 1. The following procedures shall only be reimbursed once in a lifetime per eye. RVS code Description ‘Removal of Bye 65051 | Bvisceration of ocular contents; w/o implant (65093 _ | Bvisceration of ocular contents; w/ implant ‘65101 | Enucleation of eye; w/o implant ‘65103 | Enucleation of eye; w/ implant, muscles not attached to implant ‘65105 _ | Enucleation of eye; w/ implant, muscles attached to implant ‘65110 | Exenteration of orbit without skin graft, removal of orbital contents; only gst12 | Exeateration of orbit without skin graft, removal of orbital contents; w/ 2 : therapeutic removal of bone ‘Exenteration of orbit without skin graft, removal of orbital contents; w/ muscle ‘of myocutaneous fap 65114 Page 3.0f8 E texmphitheath —wunwfacebook.conPhitHeatth — YTB www.youtube-convteamphithealth I actioncenter@philheath.gov.phy2, To reiterate, the following RVS code 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, and 66987 under “Removal Cataract” shall be claimed only ‘once in a lifetime per eye as listed in Annex 2 ~ List of Procedure Case Rates (Revision 1.0) of PhilHealth Circular No. 008 — 2015. It shall also include RVS code 66830. To illustrate: Patient A RVS code | Laterality | Date performed ‘Remarks 66983 [Right eye | June 1, 2015 Pay (66983 __| Lett eye June 3, 2015 Pa 66840 | Right eye | September 5, 3015 | Denied, under the same group of “Removal Cataract” D. Reimbursement policy for RVS codes 66820 and 66821 RVS code Description Discission of secondary membranous cataract (opacified posterior lens 66820 _ | capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens 66821 | capsule and/or anterior hyaloid); laser surgery (e.g., YAG laset) (one or more stages) 1. Claims for RVS codes 66820 and 66821 shall not be compensable if done less than 90 days after ‘cataract surgery on the same eye. Both procedures can only be done once ina lfetine per ge. To illustrate: ‘PREVIOUS CATARACT CLAIM Claim SURGERIES Procedure/ REMARKS Procedure/Date performed Date performed | RVS code 66987 RVS code 66820 Pay Right eye Right eye November 1, 2014 February 15, 2015 Z| RVS code 66987 RVS code 66820 Pay Right eye Right eye November 1, 2014 June 15, 2015 3 | RVS code 66987 RVS code 66820 Py Lftge Lftor April 1, 2016 July 1, 2016 4 | RVS code 66987 ‘RV sode 66820 Dery dain Lfftge Liftge Abril 5, 2016 Jiby 4, 2016 2 RVS 66820 and 66821 shall be exempted jrom the laterality rule. For bilateral discssion procedures (either RVS 66820 or 66821) done in one operative session or with less than one day interval (within same or diferent confnemnents), the stond dscssion procedure shall be paid at 50% of the case rate. However, if there is at least one day interval between procedures (within samse or Afferent onfinements), the second disission procedure hall be paid the full ease rate Page 4 of 8 EE teamphithealth — www facebookcomPhitHeatth Yu wwwyoutube.com/tcamphithealth MJ actioncenter@philhealthgov.phCLAIM Case Procedure/Date performed Remarks 1 Eisst Case Rate: RVS code 66821 Pay first case rate full and Right eye 150% for second case rate June 15, 2015 ‘Second Case Rate: RVS code 66821 Left eye June 15, 2015 . 2 | BintCaw Rate RVS cod 66827 Pay fil ease rae for Bath clas ye Jus 172016 Eint Cass Rates RVS sods 66821 Liftge Ji 3, 2016 3. Both RVS codes 66820 and 66821 shall automatically be subjected to post-audit. E, RVS codes/procedures exempted from the 90-day single period of confinement rule RvScode | Description Condition/Rules oe soettey CHOBE | Witzeciomy, T, Exempted from the 90 day 1. Medical Specialise mechanical, Single Period of Confinement pars plans approach | rule for the following medical | a. Philippine indications only: “Academy a, HAB.1 (Vitreous (of Ophthalmology bbaemotrhage) (PAO) b. H440 Purulent endophthalmitis) 4, trained in EENT 2A justifcation 10 support the (performance of the proedare shall be | OF subtted in ling of elas for cases i tom by the same surgon bo \® General Practitioner performed the ocxdar surgery that Jed | With completed ‘10 its complication, tesidency training in Otherwise, the claim shall be Ophthalmology denied. 3. Subject to Automatic Post- Audit 7089 | Vitzectomy, Tf oltretony ts done ta ome : - mechanical pers ‘confinement with cataract extraction, Medical Specialist Nai 1 plana approach, with | PhilFlealb call reimbarsevtrtomy | yi aing removal of dropped | ondy. If vitrectomy and catanact ppp bo! IOL extraction ae performed in siparate vou i ee 67050 | Viteectomy, confinersents , both procedures shall be AO) ey & s a mechanical pars reinbursed. S plana approach; with $3 phacofragmentation | 2. Subject to Automatic Post ialeeuniadsaianic 29 fordroppedlens | Audit nucleus Th 6 8 | | Page of 8 EG teumphitheath —www-facebookcomvPhilttealth — Yo www. youtube com/eamphithealth if nctioncenter@philheaith gov.ph+ F, Other Supplementary Guidelines 1 Ophthalmic surgical (imludes cataract surgeries) and aphthalc laser procedures shal be reimbursed when performed by an accredited General Practitioner with Completed Residency Training in Ophthalmology (PbilHleatth Accreditation Number starting with 1501 and 1503) or by a Medical Specialist of PAO or a Medical Specialist trained in Eye, Ear, Nose, Throat (EENT) Philtlealth Accreditation Number starting with 1304 and 1314, respetvel)) unless otherwise specified. A General Practitioner with completed residency training shall submat the corified true copy of the sartfcae of complted residency training in Opbtbalmoegy fo the concerned PRO for evaluation and tagging in the accreditation database ‘The removal of comeal, comeo-scleral and conjunctival sutures cannot be claimed using the following RVS codes: RVS Code Description (65205 ___| Removal of foreign body, external eye; conjunctival, superficial ‘6510 | Removal of foreign body, external eye; subconjunctival or scleral, with slit Jaap (65222 | Removal of foreign body, external eye; comes, with sit lamp The Faod and Drug Administration Philippines - registered intraocilar lens (OL) sticker or box. used in th cataract surgery shall be attached t0 Claina Form 2 for claiming the following procedures: “RVS Code Desoto “Ecxtacapanlar cataract removal vith insertion of intraocular as praatesis (ona stage procedure), reanual or mecbanical technique (ey, irigation and aspiration or 56992 | Phavoemudsifcation), comple, requiring devs or tcbniques not generally used in rontine cataract surgery (og iris expansion device, suture support for intraaclar lens, Primary pasterir capsullorbexis) or performed on patients in the anobbogenie developmental tage (66993 | Itiracapentar cataract extraction wf incrtion of intraocular lens prostbss (one rage procedure) ‘soae4 | Extracapanlar cataract removal wf insertion of intraocular len prostbcs (one stage procedure), (ogy irigation and aspiration) 66985 | Insertion of intraocular lens prosiess, not avcated with cataract removal 66986 | Exchange of intrancular lens (66987 | Exsracapsnlar cataract removal w] insertion of intraoclar lene protbeis (oe stage procedure), (eg, phacoerlsifaton In transition, the JOL sticker or box should be labeled with but not limited t0: 1) product or brand ‘nanze; 2) reodel or reforence code; 3) manufacturer; and serial numaber until Angust 31, 2016 (1 cout of 3 labels should be present and seri mer). Therafier, all three (3) labels and serial umber should be present. Otherwise, the clain shall be denied. Asis, one (1) JOL sticker shall be placed on the operative record and shall be part of the chart 6 a ‘This shall be checked during monitoring, B23 22 8. To miterate, for cataract surgeries covered by the Cataract Pre-suery Autborization (CPSA), 28 PhilFlealth shall authorize only up to a maxinmmn of fifty (50) approved requests fr pre-sugery 2 autoricaton per PhilHleal-acreditd ge surgeon per month wot exeeding ten (10) sebeduled ncgeries per day per PhilElealh-aceedited eye surgeon excep for those performed by residents in- 8 training under th eye surgeon's supereision in accredited government or private HCI with a : real Page 6of8 E tcanphineatn HE wonfcstonccon/Pieaths YoRED wonngoutbecomteanphiteath Mf sconcener@phitealt.gov.phPhilippine Board of Ophthalmolngy accredited residency training program. The patients of residents. in training not subject to limit shall onky include non-private, service and NBB eligible patient, ‘To illustrate: Dr. Juan Dela Cruz, an accredited health cate professional has the following requests for Cataract Pre-Surgery Authorization: Tncluded in the Hit comnts ted | Classification of | Category ot | Numbetof | per health care sats HCI ient ipproved fessional? ¥ = pat psa | Profesional? Yes or “Ruggast 5, 2015 | Pavate hosphal —| Pavate 3 Yes ‘Government : Angust 62015 | Beres Paivate 10 Yes ‘Hagust9, 0015 __| Private ASC Pavate 5 Yes ‘August 11, 2015 ~| Peivate hospital | Private 9 Yes Government hospital with no August 15,2015 | accredited Non-ptivate 5 Yes residency training in Ophthalmology , Sponsored member August 17,2015. | Prive asc | Sponsored me 2 Yes : ‘Sponsored member ‘Avgust 19,2015 | Private asc | Sponsored me 2 Yes Seavice patient a Paivatehosptal | PO taper! with accredited a with Anges, 2015, | rey ning | SoBUENE sing 5 No in Ophthalmology | OF o¢ residents ‘Sponsoed momar of Government boptal | PhilHea at part of y vith anredied | traning progr, with Argst 22,2015 | recency raining in | consultant signing for ve Opbibalaaly | patent of reidents ‘Ragust 23, 2015 | Paivate hospital | Private 3 Yes Private Request is denied because Dr, Dela Cruz : already exceeded the Avgust 25,2015 | Private ASC 1 erctocraaee month that are subject to the limit Total No. of Approved CPSA: 66 Total No. of CPSA not subject 0 init: 16 Total No. of Surgeries for Angus: 66 6. To reiterate, CPSA shall no longer be required in cases ofcildbood and secondary (eg, trawmatic, glaucomatous) cataracts. The clinical abstract (original or cetfed tre copy) ora completely and ‘properly fled out Claim Form 3 (page 1) shall be attached to CE2 for monitoring and evaluation. Otherwise, the clain shall be returned to sender. Page 7 of 8 G teamphitheatth — HH vewwfacebookcomPhitHteaith — Y(ED yoww.youtube.com/eamphilhealth Mi sctioncenter@phithealthgov.ph,IV. - TRANSITORY PROVISION Clnims for ophthalmic surgical and ophthalmic laser procedures by EENT specialists performed starting July 15, 2015 onwards shall be reimbursed subject to existing rules and regulations. V. MONITORING AND EVALUATION The health care provider shall be subjected to the mules on monitoring and evaluation of performance as provided for in PhilFlealth Circular No. 54, s-2012: Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS) and PhilHealth Circular No. 031-2014 re: Health Cate Provider Performance Assessment System (HCP PAS). This Circular shall be reviewed periodically and as necessary. ‘VI. REPEALING CLAUSE All provisions of previous issuances, circulars, and directives that are inconsistent with any of the provisions of this Circular for this particular circumstance wherein the same is exclusively applicable, are hereby amended, modified or repealed accordingly. ‘VI. SEPARABILITY CLAUSE In the event that a part or provision of this Circular is declared unauthorized or rendered invalid by any Court of Law or competent authority, those provisions not affected by such declaration shall remain valid and effective. Vu. EFFECTIVITY The new provisions of this Circular shall take eft for claims with admission dates starting July 1, 2016 unless otherwise speafed. Yt shall be published in any newspaper of general circulation and shall be deposited thereafter with the National Administrative Register at the University of the Philippines Law Center. 1X, ANNEX New case rate amount for selected procedures listed in Annex 2 ~ List of Procedure Case Rates (Revision 3.0) pdf file and online inguity “Search Case Rates” utility shall be available www.philhealth govph -sosexa HET cP MOCEDINNCAR RATS QHMSON 2 AND SUFFLSIENTARY CUDELDUSFOR ALLEASERATS| Page 8 of 8