[ PHIC PHILHEALTH CIRCULAR NO. 09, S. 2004, March 12, 2004 ]
AMENDMENT TO PHILHEALTH CIRCULAR NO. 24 & 25, SERIES OF 2003
1. Pregnancy-related cases covered by the sufficient regularity rule for Individually Paying Program (IPP) members include all primary conditions with the following ICD-10 codes:
2. All claims for medically necessary care of the newborns of mothers covered by the NSD package in hospitals shall be reimbursable and classified as an ordinary medical case type. The following are considered as "medically necessary":
Claim applications for newborn care shall be attached to the mother's claim for the NSD package. It is reiterated that inappropriate medicines and diagnostic examinations shall not be reimbursed.
3. Philhealth claim Form 4 shall be required for all claims for the NSD package with discharge date starting the effectivity date of this circular. All claims that failed to use the required form shall be returned to the hospital for accomplishment of Form 4 effective for all discharges from May 1, 2004.
4. In addition to these amendments, the following are reiterations for Circular No. 25 s. of 2003.
5. Furthermore, the following are corrections to typographical errors in Circulars No. 25, s. of 2003.
The above amendments and clarification shall be effective for all discharges from May 1, 2004. All other Circulars consistent herewith remain in full force and effect.
Please be guided accordingly.
Adopted: 12 March 2004
(SGD.) FRANCISCO T. DUQUE, III, MSc.
President and CEO
O30.0 Twin pregnancy O30.9 Multiple gestation, unspecified O40 Polyhydramnios O47 False labour O48 Prolonged pregnancy O80 Single spontaneous delivery O81 Single delivery by forceps and vacuum extractor O82.0 Delivery by elective caesarean section (Repeat CS not otherwise specified) O82.8 Other single delivery by caesarean section O82.9 Delivery by caesarean section, unspecified O83 Other assisted single delivery O84 Multiple delivery
2. All claims for medically necessary care of the newborns of mothers covered by the NSD package in hospitals shall be reimbursable and classified as an ordinary medical case type. The following are considered as "medically necessary":
a. Cord care
b. Care to prevent eye infections
c. Care to prevent bleeding problems
d. Care for babies at risk for infection
e. Care for babies at risk for blood sugar abnormality
f. Nationally accepted screening tests for inborn errors of metabolism
Note: Currently no test (letter f) is compensable as there has been no declaration of national acceptance for any screening tests. Only upon the declaration of national acceptance and as concurred and acknowledged by PhilHealth shall any test/s be covered.
Claim applications for newborn care shall be attached to the mother's claim for the NSD package. It is reiterated that inappropriate medicines and diagnostic examinations shall not be reimbursed.
3. Philhealth claim Form 4 shall be required for all claims for the NSD package with discharge date starting the effectivity date of this circular. All claims that failed to use the required form shall be returned to the hospital for accomplishment of Form 4 effective for all discharges from May 1, 2004.
4. In addition to these amendments, the following are reiterations for Circular No. 25 s. of 2003.
a. Normal spontaneous delivery with premature rupture of membranes (PROM) is covered by the NSD package.
b. The management of first and second-degree perineal lacerations is included in the coverage of the NSD package. For claims with third and fourth-degree laceration, hospital may seek to be reimbursed based on the Relative Value Unit of the procedure (59409=RVU 50). In such case, complete accomplishment of PhilHealth Form 2 shall be required.
5. Furthermore, the following are corrections to typographical errors in Circulars No. 25, s. of 2003.
a. The payment for Operating Room cited on Case #2 on page 2 of the Circular No. 25 shall be 2,160 pesos for a secondary hospital and not 3,490 pesos.
b. Based on PhilHealth Circular No. 24, 3. 2003, the eligibility requirements written on page 7 of Circular No. 25 (IPP member whose delivery date is January 2004) shall be interpreted as follows:
c. The example given on Case # 9 on page 4 of the same Circular shall be interpreted as follows:
Case # 9 G1 - Normal Delivery (1st ) - Package G2 - Cesarean Section Delivery (2nd ) - Pay RVU (59514) G3 - Normal Delivery (VBAC) (3rd ) - Pay RVU (59612) G4 - Normal Delivery (4th ) - Not covered G5 - Cesarean Section Delivery (5th )
- Pay RVU (59514) G6 - Normal Delivery (VBAC) (6th ) - Not covered
The above amendments and clarification shall be effective for all discharges from May 1, 2004. All other Circulars consistent herewith remain in full force and effect.
Please be guided accordingly.
Adopted: 12 March 2004
President and CEO