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(NAR) VOL. 20 NO.3 / JULY - SEPTEMBER 2009

[ PHIC PHILHEALTH CIRCULAR NO. 31, S. 2009, July 29, 2009 ]


Date Filed: 11 August 2009

In order to facilitate the payment of professional fees for anesthesia services, please be guided by the following rules:

1) The following anesthesia services are considered as compensable:
a) General anesthesia administered as inhaled or injected anesthetics
b) Regional anesthesia whether spinal, epidural or peripheral nerve blocks
c) Sedation given via injection, mouth, rectum or nasal route

2) Professional fee for local anesthesia either given through local infiltration, drops, spray or ointment is considered non-compensable. However, claims for the local anesthetic agent (e.g., lidocaine 1% vial, 5 ml) may be reimbursed under drugs and medicines subject to existing guidelines.

3) Monitored anesthesia care (MAC) is a type of physician service provided by an anesthesiologist wherein the patient undergoes a procedure under local anesthesia with or without sedation and analgesia. The process is monitored by an anesthesiologist to continually monitor and assess the patient’s vital signs, manage cardiovascular instability, give sedatives, correct the level of sedation, or convert to general anesthesia as the need arises.

4) MAC includes all aspects of anesthesia service (preoperative visit, intraoperative care and postoperative anesthesia management).

a. Professional fee for MAC may be reimbursed to PhilHealth provided that the following 2 conditions are present:
i) MAC is performed to facilitate performance of the following procedures  covered by PhilHealth (see Annex[*]); and,

ii) The patient’s clinical condition may warrant performance of MAC:
(1) Patient of extreme age, under 1 year and over 70
(2) Cognitive impairments (e.g., mental retardation, autism, dementia)
(3) Psychological impairments (e.g., schizophrenia, bipolar disorders, post- traumatic stress disorders)
(4) Extreme anxiety disorders
(5) Patients with systemic disease (e.g., CAD, COPD, emphysema, end-stage renal disease, diabetes, hypertension)
(6) Critically-ill patients

b. Professional fee for MAC for diagnostic procedures and services with no relative value units (e.g., CT scan, MRI) shall not be reimbursed.

c. MAC services for cataract surgery paid via case payment (RVS code 66983, 66984, 66987) are also not covered by PhilHealth.

5) Claims for professional fee for MAC and conscious sedation are required to  submit a properly accomplished Anesthesia Record attached to PhilHealth Claim Forms and Operative Technique.

This Circular shall take effect for all claims with admission dates starting September 1, 2009.

The provisions of previous Circulars, Office Orders and other related issuances that are not inconsistent with any provisions of this Circular remain in effect.

Please be guided accordingly.

Adopted: 29 July 2009

President and CEO

[*] Text Available at Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City
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