ANNEX 2-LIST OF PROCEDURES CASE RATES (REVISION 2.0) AND SUPPLEMENTARY GUIDELINES FOR ALL CASE RATES

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1 Republic oftlte Pflilippines PHILIPPINE HEALTH INSURANCE CORPORATION Citystale Centre, 709 Shaw Boulevard, Pasig City Call Center (02) Trunkline (02) PHILHEALTH CIRCULAR No. 01: TO ALL PHILHEALTH MEMBERS, ACCREDITED HEALTH CARE PROVIDERS (HCPs), PHILHEALTH REGIONAL OFFICES (PROs), AND ALL OTHERS CONCERNED SUBJECT ANNEX 2-LIST OF PROCEDURES CASE RATES (REVISION 2.0) AND SUPPLEMENTARY GUIDELINES FOR ALL CASE RATES I. RATIONALE As per Sections 35 (objective) and 36 (functions) of the revised IRR ofra 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 the future enhancements of All Case Rates policies, the possibility of several changes shall be reflected to adapt to the diversified scopes of professional practice and prevailing clinical setting. II. SCOPE This Circular shall cover the following revisions for selected procedures listed in Annex 2 - List of Procedure Case Rates (Revision 1.0). A. Relative Value Scale (RVS) codes/ procedures with.changes in case rate amount and /or conditions for claiming. B. RVS codes/ procedures that shall be claimed only once in a lifetime per eye C. Reimbursement policy for RVS codes and D. RVS Codes exempted from the 90 day single period of confinement rule / E. Teptporary Delisting of Additional RVS Codes F. Other Supplementary Guidelines III. GUIDELINES The selected procedures listed herein shall now be used for reference by accredited health care providers and Phi!Health members/ dependents in claiming for Phi!Health reimbursements. L-...:- - Page 1 of7 (S teamphilhealth - Ycoil!ml I!& actioncenter@philbealth.gov.ph

2 ' A. Procedures with changes in case rate amount RVScode Description (New) Health Care Professional First Institution fee Case Rate fee Removal of foreign body, external eye; cornea, with 4,180 2,500 1,680 slit lamp Destruction of Cutaneous Vascular Prolifetative Lesions (e.g. Laset Technique) 6,000 3,800 2, Conditions for claiming RVS code [Destruction of Cutaneous Vascular Proliferative Lesions (e.g. Laser Technique)]. RVS code shall only be claimed relative to the following conditions: ICD10 Description Maximum Interval in Number of Can only be between sessions per performed by procedures patient D18.0 Hemangioma, 6 30 days Diplomate/Fellow/ any site Consultant of Angioma NOS Philippine Detmatological Society (PDS) Q82.5 Congenital 6 30 days Diplomate/Fellow/ non-neoplastic Consultant of naevus Philippine (portwine) Detmatological Society (PDS) B. RVS codes/ procedures that shall be claimed only once in a lifetime pet eye 1. The following procedures shall only be reimbursed once in a lifetime pet eye. ' ' a: P.I.'J i RVScode Description \ Removal of Eye! Evisceration of ocular contents; w / o implant Eviscetation of ocular contents; w / implant Enucleation of eye; w / o implant z Enucleation of e; w / im_plant, muscles not attached to implant Enucleation of eye; w I implant, muscles attached to implant Exenteration of orbit without skin graft, removal of orbital contents; I only Exenteration of orbit without skin graft, removal of orbital contents; w / therapeutic removal of bone Exenteration of orbit without skin graft, removal of orbital contents; 0 w/ muscle or myocutaneous flap Page2of7 l5 teamphilheallh YouiJm II actioncenter@philheallh.gov.ph

3 ., ' g j 2. To reiterate, the following RVS codes 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, and 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) ofphiihealth Circular No To illustrate: Patient A RVScode Laterality Date performed Remarks June 1, 2015 Pay Left eye June 3, 2015 Pay September 5, 2015 Denied, under the same group of "Removal Cataract'' PatientB RVScode Laterality Date performed Remarks Left eye September4, 2014 Pay Jnly 11, 2015 Pay Left eye November 6, 2015 Denied, under the same group of "Removal of Eye" C. Reimbursement policy for RVS codes and RVScode Description Discission of secondary membranous cataract (opacified posterior lens capsule and/ or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens capsule and/ or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages) 1. Claims for RVS and shall not be compensable if done less than 180 days after cataract surgery on the same eye To illustrate: PREVIOUS SURGERIES CLAIM Claim Procedme/Date Procedme/Date REMARKS performed performed 1 RVS code RVS code Deny claim November 1, 2014 February 15, RVS code RVS code Pay November 1, 2014 June 15, 2015 Page 3 o 7 teamphilhealth I Y"iim actioncenter@philhealth.gov.ph

4 .,.. 2. The tule on laterality applies for both RVS and To illustrate: CLAIM Procedure/Date performed Caset First case rate RVS code June 15, 2015 Remarks Pay first case rate full and 50% for second case rate Second case rate RVS code Left eye Tune 15, Both RVS codes and are covered by the rule on single period of confinement. Thus, claims for either of the RVS codes done on the same eye shall not be reimbursed if done within 90 days of each other. 4. Both RVS codes and shall automatically be subjected to post-audit. To illustrate: Case PREVIOUS CLAIM CLAIM Procedure/Date Procedure/Date performed performed Remarks 1 RVS code RVS code Deny April10, 2015 Tune 15, RVS code RVS code Pay I T anuarv 10, 2015 Tune 15, RVS code RVS code Pay, Tanuarv 10, 2015 Tune 15, RVS code RVS code Pay I Tanuarv 10, 2015 Tune 15, 2015 D. RVS Codes exempted from the 90 day single period of confinement tule. RVSCode Description Conditions/Rules Can only be performed by Vitrectomy, 1. Exempted from the Medical Specialist of mechanical, pars day Single Period of the Philippine plana approach Confinement tule for Academy of the following medical Ophthalmology indications only: (PA.0l Pagc4of7 ['; tearnphilhealth I Ylllli!m actionceoter@philhealth.gov.ph

5 .. RVSCode Description Conditions/Rules Can only be _perlormed by a. H43.1 (Vitreous Haemorrhage) OR b. H44.0 (Purulent endophtbalmitis) 2. General Practitioner 2. The procedure should with completed not be done by the residency training in same surgeon who Ophthalmology performed the ocular surgery that led to the complication. Otherwise, the claim shall be denied. 3. Subject to Automatic Post-Audit Vitrectomy, 1. Phi!Health shall ouly Retina Specialist of the mechanical, pars reimburse the Vitreo-Retinal Society plana approach, Vitrectomy procedure of the Philippines with removal of if done in one sitting (VRSP) ofpao dropped IOL with cataract surgery. 2. Subject to Automatic Post-Audit Vitrectomy, 1. Phi!Health shall only Retina Specialists of the mechanical, pars reimburse the Vitreo-Retinal Society plana approach; Vitrectomy procedure of the Philippines with if done in one sitting (VRSP) ofpao phacofragmenta- with cataract surgery. tion for dropped 2. Subject to Automatic lens material Post-Audit E. Temporary Delisting of Additional RVS Codes RVSCode Description Destruction by any method, including laser, w / or w / o surgical curettement, all benign facial lesions or premalignant lesions in any location, or benign lesions other than cutaneous vascular proliferative lesions, including local anesthesia; anv number of lesions Destruction by any method including laser of benign skin lesions other than cutaneous vascular proliferative lesions on any area other than the fuce, including local anesthesia; anv number of lesions Electosurgical destruction of multiple fibrocutaneous tags; all lesions Paring or curettement of benign hyperkeratotic skin lesion w / or w / o chemical cauterization (such as verrucae or clavt) not extending through the stratum corneum (e.g., callus or wart) wl or wlo local anesthesia; single lesion Paring or curettement of benign hyperkeratotic skin lesion w I or w I o chemical cauterization (such as verrucae or clavt) not extending through the stratum corneum (e.g., callus or wart) wl orwlo local anesthesia; two to four lesions Page 5 of7 l.. teamphilheallh I v.. a actiancenter@philhealth.gav.ph

6 .. RVSCode Description Paring or curettement of benign hyperkeratotic skin lesion w I or w I o chemical cauterization (such as verrucae or clavi) not extending through the stratum corneum (e.g., callus or wart) w I or w I o local anesthesia; more than four lesions F. Other Supplementary Guidelines 1. Ophthalmic surgical (includes cataract surgeries) and ophthalmic laser procedures shall be reimbursed only when performed by an accredited General Practitioner with Completed Residency Training in Ophthalmology (PhilHealth Accreditation Number startiug with 1501) and Medical Specialist of the PAO (PhilHealth Accreditation Number starting with 1304). 2. The removal of corneal, comeo-scleral and conjunctival sutures cannot be claimed using the following RVS Codes: RVSCode Description Removal of foreign body, external eye; cornea, with slit lamp Removal of foreign bo_dy, external eye; conjunctival, superficial Removal of foreign body, external eye; subconjunctival or scleral, with slit lamp 3. One of the intraocular lens (lol) stickers (with serial number) used in cataract surgery shall be placed on the lower right hand comer of the CF2 (Please see attached sample). Absence of such will cause denial of the claim. Another IOL sticker should be placed on the OR technique and shall be part of the chart. This shall be checked during monitoring. 4. For cataract surgeries covered by the Cataract Pre-surgery Authorization (CPSA), PhilHealth shall authorize only up to a maximum of fifty (50) requests for presurgery authorization per PhilHealth-accredited eye surgeon per month not exceeding ten (1 0) scheduled surgeries per day per PhilHealth-accredited eye surgeon. IV. MONITORING AND EVALUATION The health care provider shall be subjected to the rules on monitoring and evaluation of performance as provided for in PhilHealth Circular No. 54, s-2012: Provider Engagement through Accreditation and Contracting for Health Services (PEACHeS) and PhilHealth Circular No re: Health Care Provider Performance Assessment System (HCP PAS) ,This Circular shall be reviewed periodically and as necessary. \ REPEALING CLAUSE provisions of previous issuances, circulars, and directives that are inconsistent with any of Q) the provisions of this Circular for this particular circumstance wherein the same is exclusively 2 pplicable, are hereby amended, modified or repealed accordingly. I 0 -plfil ealth Page of7 I YouiJil IJi actionceoter@pbilhealth.gov.ph

7 ' '' VI. SEPARABIUTY 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. VII. EFFECTIVITY This Circular shall take effect for admissions effective July 15, 2015 and onwards. It 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. However, for Section III item F.4, it shall become effective August 1, 2015 and onwards. VIII. ANNEX New case rate amount for selected procedures listed in Annex 2 -List of Procedure Case Rates (Revision.0) pdf file and on-line inquiry "Search Case Rates" utility shall be available at SUBJECT ANNEX 2- UST OF PROCEDURES CASE RATES (REVISION 2.0) AND SUPPLEMENTARY GUIDEUNES FOR ALL CASE RATES Page 7 of7 I'... ' (q teamphilhealth Yau(i!l II actioncenter@philhcalth.gov.ph

8 SAMPLE ONLY Thll fqtm I'IIIJ' r::e rrcduceu 8..'\CIII NCT FOR SAl.E CF2 (Oaim Form 2} revised Novemer :.aaren. I,Nalnec!Patient: oet.a CR.U:Z.JUANA - F.= ,.p,...,.,ir!ft1u1 ::z. \'llaapalienl rofen-o cr ancaner Hulin CUolnUihman CH0)7 II I? NO D 'Ia -----;;;;'"'"""'""';;;;;;-;;;;;;;.,.;;;;,;;,;;=" " """--- - tu!\:w-a-..ra- c.,,.,., c. OSotl.IClB';eC.: 1 "' 6,--, 2,0, I,,&"",,...l"azlent - Ci511icn: (SCioQ cnly 1) 3. Co:lflnomon1 F'et104: a.c.e.a.:m::::,0,4.-, 1,.-. '2..,0, l.s-, o.tme.ldm.uecl 9..J:@A.-.tnr'M -..,., Ti"r.e 0150' L., :, o, o,c».a f3 FU - D c. - Dl!le. l_.l...j. '--'"==-'"--' 0-0 t. TrGnlfCITediA!:fcmld oil S. Tt oj mcu:latlcn: SENILE" 7. Dlsd\at;e D;-snol.!-.r 01 (Use dltlcnal 0"2 11 nnary) ICD-10 RBiered (d' uw.o -.yl._ CA"TA:RAGT OS tf:zs.qo t. PH.ACCeMut.sJAl'A-TJOolJ < l W/ Ft.-lOt. OS L.. o.s z-aerur!it PeCocle: c. kr40"(reu"c.o/jgf""' == == , d Rr7BDOTYo m 0 Uar!l:erla!OI e Fct-EM t- u..-mmn»/--uiod... gt>_,j J:-E...,tlll4:>.r.avrf.AIIroi),.. Jmc...,p,'i(JatiJ I DatOARII C4iy3AR;\/ O..r7 RIG Olh.,I(Spe;frl f. Fer c.- OEssK!tii!INihrtiCITIC;fll os::i-tal op.c.,tlclrnt-,forne.. borneenl.-,g,. t,j/f;;/1/ibsrft:rsiwt.k Fc.l uat N-corn (d'ikii. a;:;:llcable bouii) L...:ICIQ)T>g!Xr ITme!',c:rtl actlf..,!lelm QB:o.v.oon niiis8y..- L Er.J'Skbte>Sb'IDT.!ad. I e,-e \br.-.mkrzic:n U l.icn-dmcarwti:i:jboj'rorca"e=r.;n:zaa. f:r:ji',:hiji'ards'ttwrmenl laboratory Nurnbar; 9, Pnlll'l ttf1 Elllll\ fll lcd 10or R\ISC04a: a FnrCR!:e --'6"-"t;q,_,J}<...l"'fc... MODEL; PO"''"' L.ENGTI..(!;;::T}: CPTICI';_<i!,= SNSOWF 15.5 D 13.0mm 6.Cmm