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(NAR) VOL. 15 NOS. 3-4 / OCTOBER - DECEMBER 2004

[ PHIC PHILHEALTH CIRCULAR NO. 28, S. 2004, November 12, 2004 ]

REIMBURSEMENT GUIDELINES FOR VITRECTOMIES PERFORMED AT THE TIME OF CATARACT EXTRACTION



This circular is issued to facilitate correct assignments of Relative Value Units (RVU) for performance of vitrectomy procedures at the time of cataract surgery.

1. Vitrectomy involves the removal of vitreous from the posterior chamber of the eye and may be performed as an independent procedure or in conjunction with other eye procedures such as cataract extraction.

2. Planned vitrectomy performed at the time of cataract extraction shall be paid provided that an indication specified in the admitting diagnosis supports the performance of the procedure.  In such case, payment shall be based on existing rules:

  1. multiple procedures performed thru a single opening shall be compensated using the procedure with the highest RVU.
  2. Outpatient services for surgical procedures with total RVU of 201 and above shall be paid based on RVU of 200.

Example 1: Admitting diagnosis: Senile cataract, diabetic retinopathy
        Procedures done:
 
66984 Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., irrigation and aspiration)
      180   
67036 Vitrectomy, mechanical, pars plana approach
400

Reimbursement: 67036 at 400 RVU if admitted; 200 RVU only if outpatient case

3.    When an unplanned vitrectomy is performed during cataract surgery as a result of intraoperative complication of posterior capsular rupture only the cataract extraction shall be paid.

Example 2: Admitting diagnosis: senile cataract
        Procedure done:
 
66984 Extracapsular cataract removal w/ insertion of intraocular lens prosthesis (one stage procedure), (e.g., irrigation and aspiration)
180
  
67005 Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal
350
   
 Reimbursement: 66984 only at 180 RVU 

These rules shall be applied to all claims with admission dates starting January 1, 2005.

For your information and guidance.

Adopted: 12 Nov. 2004


(SGD.) DR. FRANCISCO T. DUQUE III
Secretary
President and CEO
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