Pursuant to the approved PhilHealth Board Resolution Number 1208 series of 2009 that aims to update and rationalize the current case type classification to make benefits more responsive to the members ™ needs, the following clarification and guidelines on the revised case type classification are hereby issued:

1. Case type is an assessment of complexity of illness assigned to a case after discharge. It is measured on a four (4) scale system, from A to D, with case type A being the least complex and case type D as the most severe.

         

Case Type	Severity	Example
A B C D	Simple Moderate Severe Extremely severe	Upper respiratory tract infection (J06.9) Status asthmaticus (J46) End stage renal disease (N18.0) Deep intracerebral haemorrhage (I61.0)

2. ICD-10 codes considered as case types A, B, C and D are listed in Annex^[*] A, B, C and D, of this Circular.

3. All ICD-10 codes are assigned with corresponding fixed case types. Hence, all claims submitted to PhilHealth, except those paid through case payment shall be paid based on the case type of primary illness.

4. Considering the severity of some illnesses/conditions, modifications in case type assignment may be considered for the following illness/condition:

a. Cases/conditions considered for automatic upgrade of case type

Illness or Condition	Upgraded to Case Type
Conditions requiring transfusion of blood or blood products	B
Pneumonia
Community-acquired pneumonia III, moderate risk (adult)	B
Pediatric community-acquired pneumonia, moderate risk (PCAPC)	B
Community-acquired pneumonia IV, high risk (adult)	C
Pediatric community-acquired pneumonia, high risk (PCAPD)	C
Malignant neoplasm
Cancer with metastasis	C
Chemotherapy session for neoplasm	C
Radiotherapy session	C
Dialysis session i.e. peritoneal dialysis and hemodialysis	C
In the event of death regardless of illness or condition	D

b. For the following illness/condition, the corresponding case type shall be considered applicable, provided the diagnosis and ICD-10 code are clearly stated in the claim form.

Description	Case Type
Chronic respiratory insufficiency	B
Multiple Drug Resistant Tuberculosis confirmed by culture	B
Nosocomial pneumonia	B
Multiple organ failure	C

GENERAL RULES FOR CASE TYPING

A. Medical

1. For coding and reimbursement of medical claims, case type will be based on the ICD-10 of the primary illness or main condition.The primary illness or main condition is the condition identified at the time of discharge as being the main reason for the patient ™s confinement, whether it is for receiving care or for investigation of a current illness or injury (please see PhilHealth Circular No. 4 s. 2002).

Example 1:

Final Diagnosis	ICD-10 Code	Case Type
Hypertension	I10.9	A
Acute pyelonephritis (Main condition)	N10	B
The final case type for this example is B.

Example 2:

Final Diagnosis	ICD-10 Code	Case Type
End stage renal disease (ESRD)	N18.0	C
Acute pharyngitis (Main condition)	J02.9	A
The final case type for this example is A.

2. In cases wherein the hospital claimed for a lower reimbursement, PhilHealth shall reimburse to the member within the amount of the remaining benefit, provided the claim is supported by an Official Receipt (OR) and Statement of Account (SoA) issued by the hospital.

3. For cases wherein there is a discrepancy between the final diagnosis and the management based on part three (III) and four (IV) of the Claim Form 2, PhilHealth may return the claim to the hospital with request for a properly accomplished PhilHealth Claim Form 3 and other appropriate documents e.g., copy of clinical chart, laboratory result, radiology result and other ancillary procedures, complete clinical abstract deemed necessary for proper evaluation.

4. For claims wherein the member or hospital request for a higher case type other than those specified in this circular, PRO - Benefit Administrative Sections may refer such requests to the Quality Assurance Committee (QAC) for their evaluation and recommendation. For such claims, it is reiterated that the complete diagnosis and its applicable ICD 10 code should be clearly stated in the PhilHealth Claim Form 2 and a properly accomplished PhilHealth Claim Form 3 should be submitted.

B. Surgical

1.For claims with surgical procedure/s and other services, the case type shall be based on the corresponding Relative Value Unit (RVU) assigned to the procedure.

Case Type	RVU	Example
A	80 and below	Simple repair of wound (RVU 10)
B	81 up to 200	Appendectomy (RVU 100)
C	201 up to 500	Whipple-type procedure (RVU 450)
D	501 and above	Surgery intracranial aneurysm (RVU 600)

2. For claims with two (2) or more surgical procedure/s (multiple surgeries), the case type shall be based on the procedure with the highest RVU.

Example 3:

Procedure	RVU	Case Type
Excision of breast lesions with frozen section	25	A
Modified radical mastectomy	150	B
Pathology consultation with frozen section, 1 block	20	A
The final case type for this example is B.

3. In cases where the case type for the medical diagnosis and the surgical procedure are different, the higher case type shall predominate.

Example 4:

	Case Type
Diagnosis: End stage renal disease (ICD 10 code = N18.0) Procedure done: Hemodialysis (RVU 10)	C A
The final case type for this example is C.

Example 5:

	Case Type
Diagnosis: Acute appendicitis without perforation (ICD 10 code = K35.9) Procedure done: Appendectomy (RVU 150)	A B
The final case type for this example is B.

C. Other Rules

1. For case type D

a. It is reiterated that all claims with primary illness/condition classified as case type D shall be required submission of PhilHealth Claim Form 3 or Clinical Abstract for proper evaluation and assessment. If PhilHealth Claim Form 3 or Clinical Abstract is not attached in the claim, it shall be returned to the hospital for completion.

b. For multiple surgical procedures wherein one procedure has an RVU of 501 and above, only the procedure above RVU 501 will use the peso conversion factor (PCF) specific for case type D (PCF of 80). Computation of professional fee for other procedures below 501 will use the baseline PCF of 40 depending on the tier category of the doctor.

Example 6:

	Case Type
Diagnosis: Deep intracerebral haemorrhage (I61.0) Procedure done: Cutdown (RVU 10) performed by a surgeon	D A
The final case type for this Example is D, however the computation of PF for cutdown will be based on baseline PCF of 56 (RVU 10 x PCF 56 = PF of 560).

c. It is reiterated that benefits for case type D can only be paid for patients admitted in Level 3 and 4 (tertiary) hospitals. Case type D in Level 1 (primary) and 2 (secondary) hospitals shall be paid as case type B and C, respectively.

d. For medical conditions classified as case type D payment of doctor ™s daily visit will depend on the rates provided for case type D.

2. For primary hospitals

a. For all cases classified as case type C and D the maximum benefit is still based on case type B.

b. Claims for Level 1 (primary) hospitals are still required to submit Claim Form 3 or Clinical Abstract except for claims paid thru case payment e.g., NSD, BTL, Vasectomy, etc.

This Circular shall be applicable to all admissions effective July 1, 2009.

All other provisions and issuances inconsistent with this circular are hereby repealed, modified and amended accordingly.

Please be guided accordingly.

Adopted: 20 April 2009

(SGD.) DR. REY B. AQUINO
President and CEO

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