Pursuant to PhilHealth Circular No. 17, s. 2007 which provides for the œdiscontinuance of compensability of claims for cataract surgery performed during medical missions and thru other recruitment schemes and limiting the number of compensable claims for cataract surgery,  the Corporation shall adopt the following guidelines for implementation:

1. For the purpose of this policy, PhilHealth refers to the definition of the following terms:

• œMEDICAL MISSION  or œCATARACT MISSION  is an outreach program for humanitarian/non-profit purposes that provides free cataract surgery to people of all ages who have limited or no means to pay.
• œCATARACT SURGERY  is the removal of the lens of the eye that has developed an opacification, which is referred to as a cataract. Following surgical removal of the natural lens, an artificial intraocular lens is implanted. Cataract surgery is generally performed by an opthalmologist (eye surgeon) at an ambulatory or inpatient setting, in a surgical center or hospital, using local anesthesia (either topical, peribulbar, or retrobulbar) or general anesthesia in special circumstances. The cataract surgeries with RVS code shall include the following:

                           
RVS Code

                      ___                                                                                                                     
Procedure

                           
                                                                                                                                           

66825
---------

Repositioning of intraocular lens prosthesis, requiring an incision
-------------------------------------------------------------------------------------------------

66830


---------

Removal of secondary membranous cataract (opacified posterior lens capsule
and/or anterior hyaloid) with corneo-scleral section, w/ or w/o
iridectomy (iridocapsulotomy, iridocapsulectomy)
-------------------------------------------------------------------------------------------------

66840
---------   

Removal of lens material; aspiration technique, one or more stages
------------------------------------------------------------------------------------------------- 66850
---------   phacofragmentation technique (mechanical or ultrasonic) e.g. phacoemulsification)
------------------------------------------------------------------------------------------------- 66852
---------   pars plana approach, with or without vitrectomy
------------------------------------------------------------------------------------------------- 66920
---------   intracapsular
------------------------------------------------------------------------------------------------- 66930
---------   intracapsular, for dislocated lens
------------------------------------------------------------------------------------------------- 66940
---------   extracapsular
------------------------------------------------------------------------------------------------- 66983

--------- Intracapsular cataract extraction w/ insertion of intraocular lens prosthesis
(one stage procedure)
------------------------------------------------------------------------------------------------- 66984

---------   Extracapsular cataract removal w/ insertion of intraocular lens prosthesis
(one stage procedure), (irrigation and aspiration)
------------------------------------------------------------------------------------------------- 66985
---------   Insertion of intraocular lens prosthesis, not associated with cataract removal
------------------------------------------------------------------------------------------------- 66986
---------   Exchange of intraocular lens
------------------------------------------------------------------------------------------------- 66987

  Extracapsular cataract removal w/ insertion of intraocular lens prosthesis
(one stage procedure), (e.g. phacoemulsification)
                                                                                                                                                  

2. All claims (includes PAO-National-and LGU-sponsored) for cataract surgeries shall not be compensated if performed under any of the following conditions:

2.1 The health care provider/s (professional and/or institution) solicit/s patients through any means or form or through any medium that violates the code of ethics of the Philippine Academy of Ophthalmology; i.e., he/she offers to or receives from a fellow physician, allied health professional or independent solicitor any fee(s) or favor(s) for the purpose of obtaining patients.

2.2 Medical missions in which a health care provider has linked up with a non-government organization or an institution in the guise of charity or community service for the sole purpose of soliciting PhilHealth patients.

2.3 Medical missions limited to PhilHealth members/beneficiaries only

2.4 Medical missions done for profit or anything that brings profit but does not promote the best interest of the patient

2.5 The health care provider/s (professional and/or institution) solicit/s patients through other recruitment schemes for the purpose of enrollment to PhilHealth.

3. The compensability of claims in PAO-sponsored and recognized community-based cataract surgery projects shall be subject to additional provisions in the Memorandum of Agreement between PhilHealth and PAO.

4. National Government or Local Government Unit (LGU)-sponsored missions conducted in any PhilHealth-accredited government facility shall be compensable subject to provisions in item no. 2. The professional fees shall be pooled subject to provisions stipulated in Rule VIII (Payment of Claims) Section 47 of Implementing Rules and Regulations of PhilHealth.

5. Any indication/s or report/s of pattern/s, indicative that such claims were done through the use of recruitment schemes, or during the conduct of a medical mission, unless herein specified, shall cause suspension of processing of claims pending legal investigation.

6. Identified erring PhilHealth-accredited providers shall be referred to the Committee on Ethics and Practice Management of PAO for appropriate action without prejudice to further action of the Corporation.

7.   PhilHealth-accredited providers (both professional and institutional providers) found to have violated this circular, after due process, shall be recommended for non-renewal or suspension or revocation of accreditation.

All other issuances inconsistent herein are hereby repealed and modified accordingly.

Adopted: 16 Nov. 2007