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(NAR) VOL. 14 NOS. 3-4 / OCTOBER - DECEMBER 2003

[ PHIC PHILHEALTH CIRCULAR NO. 39, S. 2002, October 01, 2002 ]

CLARIFICATORY RULES FOR DAY SURGERIES PERFORMED IN HOSPITALS AND AMBULATORY SURGICAL CLINICS (ASC)



As provided for by PhilHealth Board Resolution No. 487 series of 2002, the following are the rules clarifying the benefits for day surgeries performed in hospitals and freestanding ambulatory surgical clinics (ASC) as a result of the last benefit increase per PhilHealth Circular No. 35, s. 2001.
  1. Only ambulatory surgical services with a Relative Value Unit (RVU) of 200 and below in the Relative Value Scale 2001 shall be compensated. However, in the interest of patient safety, procedures with RVU of 200 and below such as cesarean section, exploratory laparotomy and other similar procedures that require more than twenty-four hours confinement shall not be compensated if performed as outpatient service. The Corporation shall issue a list of additional non compensable procedures with RVU of 200 and below or negative list in subsequent circulars.

  2. In further interest of patient safety, claims from hospitals and ambulatory surgical clinic (ASC) for outpatient services with surgical procedure or multiple surgical procedures done with total RVU of 201 and above shall be disallowed.

  3. Ambulatory surgical clinics are deemed analogous to secondary hospitals and shall be given the same benefit limits of these hospitals.

  4. Each use of the ambulatory surgical facility shall be considered as one-day charged to the 45-day annual benefit limit. Only drugs, medicines and supplies used on the day of the surgery shall be reimbursed.

  5. Only laboratory and ancillary procedures performed on the day of the surgery that are considered necessary shall be covered (e.g. intraoperative biopsies).

  6. Payment for the operating room shall be reimbursed based on the RVU of the procedure.

  7. Payment for professional fee of the surgeon shall be based on the RVU of the procedure and the existing Peso Conversion Factor (PCF). Anesthesiologist care for local anesthesia will not be covered except for regional nerve block.

  8. Surgical procedures performed in accredited ambulatory surgical clinics (ASC) with extended stay of more than twenty-four (24) hours shall be denied.

The herein above rule shall take effect for day surgeries with discharges starting December 01, 2002 and will not be interpreted as new benefits. All other rules and guidelines not contrary hereto shall remain in full force and effect.

For your guidance.

Adopted: 01 Oct. 2002

(SGD.) FRANCISCO T. DUQUE III, MD, MSc.
President and CEO

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