philhealth claims filing reducing mistakes, increasing reimbursements reducing mistakes, increasing...
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PhilHealth Claims FilingPhilHealth Claims Filing
Reducing Mistakes,
Increasing Reimbursements
Reducing Mistakes,
Increasing Reimbursements
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Know the Rules!Know the Rules!• PhilHealth does not pay for all your
health care costs.
• PhilHealth pays only for covered items and services when its rules are met.
• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth
• PhilHealth does not pay for all your health care costs.
• PhilHealth pays only for covered items and services when its rules are met.
• Members usually give a co-payment for the portion of the actual cost that is not covered by PhilHealth
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PhilHealthPhilHealth• Govt owned and controlled corporation
• Created by Republic Act 7875
• National Health Insurance Program (NHIP)
• Amended by Republic Act 9241
• Access to health care is a basic right of citizens – “Universal coverage”
• Govt owned and controlled corporation
• Created by Republic Act 7875
• National Health Insurance Program (NHIP)
• Amended by Republic Act 9241
• Access to health care is a basic right of citizens – “Universal coverage”
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Members andDependents
Members andDependents
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Our MembersOur Members
1. Employees (govt and private)
– monthly payment (3% salary)
2. Individually Paying Program (voluntary)
- quarterly payment (1,200/year)
3. Overseas Workers Program
- Annual payment (900/year)
1. Employees (govt and private)
– monthly payment (3% salary)
2. Individually Paying Program (voluntary)
- quarterly payment (1,200/year)
3. Overseas Workers Program
- Annual payment (900/year)
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Our MembersOur Members4. Non-paying (pensioner)
- no payment for life
• 60 years old
• With total 120 monthly contributions
5. Sponsored (thru partnership with LGUs)
- annual payment, eligibility for 1 year
4. Non-paying (pensioner)
- no payment for life
• 60 years old
• With total 120 monthly contributions
5. Sponsored (thru partnership with LGUs)
- annual payment, eligibility for 1 year
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Your DependentsYour Dependents
• Spouse
• Children < 21 years old
• Parents > 60 years old
–Step parents
–Adoptive parents
• Spouse
• Children < 21 years old
• Parents > 60 years old
–Step parents
–Adoptive parents
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BenefitsBenefits
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45 Days Annual Allowance45 Days Annual Allowance
• 45 days allowance per year for the principal (member)
• Another 45 days shared among dependents
• 45 days allowance per year for the principal (member)
• Another 45 days shared among dependents
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Your benefitsYour benefits• Illness requiring hospitalisation• Outpatient:
– Surgical procedures• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing
• Illness requiring hospitalisation• Outpatient:
– Surgical procedures• Cataract surgery• BTL• Vasectomy• Endoscopy• Excision• Suturing
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Drugs and MedicinesDrugs and Medicines
• Only drugs used during confinement will be paid
• Drugs must be written in generic name
• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth
*6th edition of the Philippine National Drug Formulary (PNDF)
• Only drugs used during confinement will be paid
• Drugs must be written in generic name
• Closed formulary – only drugs listed in the preferred list* will be covered by PhilHealth
*6th edition of the Philippine National Drug Formulary (PNDF)
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Anti-convulsants / Epileptics
Anti-convulsants / Epileptics
– CARBAMAZEPINE– CLONAZEPAM– DIAZEPAM– LORAZEPAM– MAGNESIUM
SULFATE– PHENOBARBITAL– PHENYTOIN– VALPROIC DISODIUM
–Gabapentin
–Midazolam
–Thiopental sodium
–Topimarate
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Anti-ParkinsonismAnti-Parkinsonism–Pirebidil
• 50 mg
–Selegiline• 5 mg
– LEVODOPA + BENSERAZIDE
• 100 mg/25 mg
• 200 mg/50 mg
– LEVODOPA + CARBIDOPA
• 100 mg/25 mg
• 250 mg/25 mg
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Case: 65 years old
Diagnosis: Parkinson’s Disease
Drugs: Levodopa + Benserazide # 60
Nifedipine 30 mg # 60 (PNDF)
Telmisartan tab # 60 (non-PNDF)
Admission: September 17 - 20
What drugs will be paid?
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Case:
Diagnosis: Parkinson’s Disease, HPN
Drugs: Levodopa + Benserazide # 60
Nifedipine 30 mg # 60
Telmisartan tab # 60
Admission: September 17 - 20
How many will be paid?
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Drugs and MedicinesDrugs and Medicines
• Only drugs, supplies, and lab
used on confinement shall be
paid
– Must be supported by official
receipts
• Only drugs, supplies, and lab
used on confinement shall be
paid
– Must be supported by official
receipts
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• physician charges separately for each patient encounter or service rendered
• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one
• Needs itemization
• physician charges separately for each patient encounter or service rendered
• expenditures increase if more services are provided or a more expensive service is substituted for a less expensive one
• Needs itemization
Fee for Service Scheme:Fee for Service Scheme:
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Computation of BenefitsComputation of Benefits
• Case type of illness
• Category of Facility
• Case type of illness
• Category of Facility
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CasetypesCasetypes
• Casetype A – Ordinary
• Casetype B – Intensive
• Casetype C – Catastrophic
• Casetype D – Super Catastrophic
• Casetype A – Ordinary
• Casetype B – Intensive
• Casetype C – Catastrophic
• Casetype D – Super Catastrophic
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Level 3 & 4 Hospitals (Tertiary)
Case-type A B C D
Room & Board* P400/day P400/day P400/day P1,035/day
Drugs and Medicines** P3,000 P9,000 P16,000 P35,635
X-ray, Lab & Others** P1,700 P4,000 P14,000 P29,430
Operating Room** RVU 30 and below = P1,060
RVU 31 to 80 = P1,350
RVU 81 up to 200 = P3,490
RVU 201 up to 500 = P3,490
RVU > 500 = P10,470
Level 2 Hospital (Secondary)
Room & Board* P300/day P300/day P300/day P660/day
Drugs and Medicines** P1,700 P4,000 P8,000 P19,725
X-ray, Lab & Others** P850 P2,000 P4,000 P10,215
Operating Room** RVU 30 and below = 670
RVU 31 to 80 = P1,140
RVU 81 up to 200 = P2,160
RVU 201 up to 500 = P2,160
RVU > 500 = P6,480
Level 1 Hospital (Primary)
Room & Board* P200/day P200/day N/A N/A
Drugs and Medicines** P1,500 P2,500 N/A N/A
X-ray, Lab & Others** P350 P700 N/A N/A
Operating Room** RVU 30 and below = P385
N/A N/A N/A
* Not exceeding 45 days for each member & another 45 days to be shared by his/her dependents** Per single period of confinement
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Benefit Periods
• PhilHealth benefits are divided into benefit
periods
• A benefit period is essentially a single
hospital stay, including re-hospitalisation of
up to 90 days
• In each benefit period, PhilHealth will only
pay 1 benefit
• PhilHealth benefits are divided into benefit
periods
• A benefit period is essentially a single
hospital stay, including re-hospitalisation of
up to 90 days
• In each benefit period, PhilHealth will only
pay 1 benefit
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Single Period of Confinement
• Example
– a 3 week chemotherapy cycle,
where a patient has treatment on
the 1st and 8th days, but nothing
on days 2 - 7 and days 9 - 21
– Medicine per session is 5,000
• Example
– a 3 week chemotherapy cycle,
where a patient has treatment on
the 1st and 8th days, but nothing
on days 2 - 7 and days 9 - 21
– Medicine per session is 5,000
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Benefit Unused Payment
16,000
January 1 16,000 5,000
January 8 11,000 5,000
January 22 6,000 5,000
January 29 1,000 1,000
February 12, 19, 0 0
90 days after January 1
New 16,000March 1
March 5 16,000 5,000
March 12 11,000 5,000
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Single Period of Confinement
• You may only avail of the unused
benefits except:
– for room and board fees
– Professional fees
until the 45 day allowance is fully
exhausted.
• You may only avail of the unused
benefits except:
– for room and board fees
– Professional fees
until the 45 day allowance is fully
exhausted.
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ProfessionalFeeProfessionalFee
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Professional Fees**
Case-type A B C D
General Practitioner P150/day not exceeding P600
P150/day not exceeding P900
P150/day not exceeding P900
P315/day not P315/day not exceeding exceeding P2,430P2,430
Specialist
P250/day not exceeding P1,000
P250/day not exceeding P1,500
P250/day not exceeding P2,500
P450/day not P450/day not exceeding exceeding P4,050P4,050
Surgeon (P40/RVU) not exceeding P16,000
(P120 /RVU for consultation) but not exceeding P47,790
Anesthesiologist 30% Surgeon’s fee not exceeding P5,000
30% Surgeon’s fee not exceeding P14,355
** Per single period of confinement
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• based on the Relative Value Units (RVU)
• The RVU must be multiplied by a Peso Conversion Factor (PCF) to become a payment schedule
• Surgeons: RVU x P 40
• Covers preoperative visits, intraoperative services, postoperative services for 90 days
• Anesthesiologist: (RVU x P 40) x 30%
• based on the Relative Value Units (RVU)
• The RVU must be multiplied by a Peso Conversion Factor (PCF) to become a payment schedule
• Surgeons: RVU x P 40
• Covers preoperative visits, intraoperative services, postoperative services for 90 days
• Anesthesiologist: (RVU x P 40) x 30%
Professional Fee
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Example:
66270 Spinal puncture
12
12 RVU x 40 PCF = Php 480
Professional Fee
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Example:
61793 Stereotactic radiosurgery 200
200 RVU x 40 PCF = Php 8,000
Professional Fee
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Example:
61500 Craniectomy w/ excision of tumor 400
400 RVU x 40 PCF = Php 16,000
Professional Fee
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Policies on PF Policies on PF
• > 2 procedures, single opening = pay highest value
• > 2 procedures, different incision site
= pay all unit values
• Procedures done on different dates
= pay all unit values
• > 2 procedures, single opening = pay highest value
• > 2 procedures, different incision site
= pay all unit values
• Procedures done on different dates
= pay all unit values
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Example:
49000 - Explor Lap - 150
44950 - Appendectomy - 100
150 RVU x 40 PCF = P6,000
Example:
49000 - Explor Lap - 150
44950 - Appendectomy - 100
150 RVU x 40 PCF = P6,000
Policies on PF Policies on PF
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Example:
49000 - Explor Lap - 150
58943 - Oophorectomy for
ovarian CA - 200
200 RVU x 40 PCF = P8,000
Example:
49000 - Explor Lap - 150
58943 - Oophorectomy for
ovarian CA - 200
200 RVU x 40 PCF = P8,000
Policies on PF Policies on PF
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Example: Bilateral Cataract Extraction
69887 - ECCE phacoemulsification - 200
200 x 2 = 400 RVU400 RVU x 40 PCF = P16,000
Example: Bilateral Cataract Extraction
69887 - ECCE phacoemulsification - 200
200 x 2 = 400 RVU400 RVU x 40 PCF = P16,000
Policies on PF Policies on PF
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Repeat Procedures:• Payment within cap• Covered by rule on single period
of confinement
Repeat Procedures:• Payment within cap• Covered by rule on single period
of confinement
Service Rendered Computed Benefit PHIC BenefitLigation, varices esophagus 10,000 10,000 Ligation, varices esophagus 10,000 6,000
Policies on PF Policies on PF
Total = 16,000
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Example:
66270 Spinal puncture
12
12 RVU x 40 PCF = Php 480
Professional Fee
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Professional Data & Charges
21. Name of Surgeon Signature & Date Signed Reduction Code
22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual
P P PDate of Operation
SurgeonBenefit Claim
PatientProfessional Charges
14. Complete Final Diagnosis
Relative Unit Value
15. Case Type Ordinary Intensive Catastrophic
16. Name of Attending Physician Signature & Date Signed Illness Code
18. BIR/TIN No. - - Reduction Code
19. Services Performed 20. Actual
P P P
17.PHIC Accreditation No.
PatientPhysicianProfessional Charges
FOR PHILHEALTH USE
Benefit Claim
PART II - PROFESSIONAL DATA AND CHARGES ( Doctor/s to Fill in Respective Portions )
26. Name of Anesthesiologist Signature & Date Signed Reduction Code
27.PHIC Accreditation No. 28. BIR/TIN No. - -29. Services Performed 30. Actual
P P P
Benefit ClaimProfessional Charges Physician Patient
Daily visit
RVU
Anesth
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21. Name of Surgeon Signature & Date Signed Reduction Code
22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual
P P PDate of Operation
SurgeonBenefit Claim
PatientProfessional Charges
Professional Data & Charges
Lumbar tap1000 480
With deduction
520
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21. Name of Surgeon Signature & Date Signed Reduction Code
22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual
P P PDate of Operation
SurgeonBenefit Claim
PatientProfessional Charges
Professional Data & Charges
Lumbar tap1000 1000
With no deduction
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21. Name of Surgeon Signature & Date Signed Reduction Code
22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual
P P PDate of Operation
SurgeonBenefit Claim
PatientProfessional Charges
Professional Data & Charges
Lumbar tap480 480
Complimentary PF; PhilHealth only
Actual PF = PhilHealth benefit
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21. Name of Surgeon Signature & Date Signed Reduction Code
22.PHIC Accreditation No. 23. BIR/TIN No. - -24. Services Performed 25. Actual
P P PDate of Operation
SurgeonBenefit Claim
PatientProfessional Charges
Professional Data & Charges
Dialysis400 400
Government hospital; Private Patient
Private hospital; Service Patient
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PAY TO DOCTOR
Private Patient, Government Hospital
NO Stamp: PF is made to the Chief
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PAY TO CHIEF
Service Patient, Pay Hospital
Name of Surgeon
NO Stamp: PF is made to the MD who signed Form 2
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Eligibility RulesEligibility Rules
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• For employed and IPP, at least 3 monthly contributions within the immediate 6 months prior to admission
• the 45-days allowance for room and board has not been consumed yet
• confinement in an accredited hospital of not less than 24 hours
• For employed and IPP, at least 3 monthly contributions within the immediate 6 months prior to admission
• the 45-days allowance for room and board has not been consumed yet
• confinement in an accredited hospital of not less than 24 hours
Are you eligible?Are you eligible?
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CaseCase• Employed member since January 2006Employed member since January 2006
• Admitted for Myelography for tumor (?)Admitted for Myelography for tumor (?)
• Paid premium up to January to March Paid premium up to January to March 20072007
• Is the claim compensable?
• Employed member since January 2006Employed member since January 2006
• Admitted for Myelography for tumor (?)Admitted for Myelography for tumor (?)
• Paid premium up to January to March Paid premium up to January to March 20072007
• Is the claim compensable?Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr
x Admit
X – start of membership
No !
6 5 4 3 2 1
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CaseCase
• IPP applied membership March 2007
• Premium paid
• Admitted April 2007 for TIA
• IPP applied membership March 2007
• Premium paid
• Admitted April 2007 for TIAJul Aug Sep Oct Nov Dec Jan Feb Mar Apr
x Admit
1st quarterX – start of membership
Yes !
6 5 4
3 2 1 3 2 1 3 2 1
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2007 P 300300
300
• What if a member enroll today, when can he start availing PhilHealth benefits?
06/08/2007
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Adverse selectionAdverse selection• Phenomenon whereby a disproportionate
share unhealthy individuals (high risk) enroll in a health plan
• Hidden information; member moral hazard• Influenced by benefit design and individual
decision• In contrast to guiding principles of social
solidarity• Example: CS, Cataract
• Phenomenon whereby a disproportionate share unhealthy individuals (high risk) enroll in a health plan
• Hidden information; member moral hazard• Influenced by benefit design and individual
decision• In contrast to guiding principles of social
solidarity• Example: CS, Cataract
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For IPP, at least 9 monthly contributions within the immediate 12 months prior to admission for the following:
1. Hemodialysis and Peritoneal Dialysis
2. Chemotherapy
3. Radiation oncology
4. Selected surgeries:• CS• D & C• Cataract• Endoscopy effective April 1, 2007
For IPP, at least 9 monthly contributions within the immediate 12 months prior to admission for the following:
1. Hemodialysis and Peritoneal Dialysis
2. Chemotherapy
3. Radiation oncology
4. Selected surgeries:• CS• D & C• Cataract• Endoscopy effective April 1, 2007
Circular 36 s. 2006Circular 36 s. 2006
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Supplier induced demandSupplier induced demand
• Demand created by doctors beyond what would have occurred in a market
• Influenced by benefit design and individual decision
• Hidden action
• Doctor moral hazard
• Demand created by doctors beyond what would have occurred in a market
• Influenced by benefit design and individual decision
• Hidden action
• Doctor moral hazard
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PhilHealth Payment 2004PhilHealth Payment 2004
Cataract (69887 & 66984)
• Total Payment: 590 million
• Total Number Claimed: 28,997
• AVPC: 20,368.83
• Average PF: 7,700
Cataract (69887 & 66984)
• Total Payment: 590 million
• Total Number Claimed: 28,997
• AVPC: 20,368.83
• Average PF: 7,700
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AdvertsAdverts• False adverts tends to deceive or
mislead the public which makes an untruthful assertion
– E.g., “Free cataract surgery for PhilHealth members “
– “No out of pocket payments for PhilHealth members”
• False adverts tends to deceive or mislead the public which makes an untruthful assertion
– E.g., “Free cataract surgery for PhilHealth members “
– “No out of pocket payments for PhilHealth members”
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AdvertsAdverts
• Cataract surgery announced as free should not be filed to PhilHealth and be offered to all regardless of PhilHealth membership status
– Why not offer it to all?
– Not free; PhilHealth as third party payor
• Cataract surgery announced as free should not be filed to PhilHealth and be offered to all regardless of PhilHealth membership status
– Why not offer it to all?
– Not free; PhilHealth as third party payor
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Solicitation of patientsSolicitation of patients
• Solicitation of patients, directly or indirectly, through solicitors or agents, is unethical
– Example: • NGO sponsorship of medical mission• Doctors paying for patients premium
– 300 pesos versus 49,000 pesos (bilateral ECCE)
• Solicitation of patients, directly or indirectly, through solicitors or agents, is unethical
– Example: • NGO sponsorship of medical mission• Doctors paying for patients premium
– 300 pesos versus 49,000 pesos (bilateral ECCE)
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RVS 2001RVS 2001
• Historically-abused procedures
– Utilization trend data– Institutional memories
• Blepharoplasty• Removal of FB, eye• Pterygium
–Excision (20) Conjunctivoplasty (60)
• Historically-abused procedures
– Utilization trend data– Institutional memories
• Blepharoplasty• Removal of FB, eye• Pterygium
–Excision (20) Conjunctivoplasty (60)
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RVS 2001RVS 2001
Upcoding or Creeping:
• In claims submission, using a higher level procedure code than the level of service actually provided
• E.g., appendectomy (100 RVU) to
AP ruptured (150 RVU)
Upcoding or Creeping:
• In claims submission, using a higher level procedure code than the level of service actually provided
• E.g., appendectomy (100 RVU) to
AP ruptured (150 RVU)
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ICD-10ICD-10
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ICD-10ICD-10
• An international classification designed to enable CONSISTENCY of coding THROUGHOUT the world.
• An international classification designed to enable CONSISTENCY of coding THROUGHOUT the world.
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The structure of the 4-character category is:
STRUCTURE OF ICD-10 CODE:
First character A to Z (Except U)
Followed by2 digits
thena point
Lastly Another digit
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There are three (3) volumes
MAIN ELEMENTS TO THE STRUCTURE OF ICD-10
There are twenty one (21) chapters
The structure of the code is alphanumeric
VOLUMES OF THE ICD-10:
Volume 1 (Tabular List) – alphanumeric listing of diseases and disease groups
Volume 2 - contains instructions and guidelines for Mortality and Morbidity coding
Volume 3 (Alphabetical Index) – comprehensive listing of all the conditions in the Tabular List
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Basic Coding GuidelinesBasic Coding Guidelines
Follow carefully any cross-references found in the index.
Refer to the Tabular List (Vol. 1)
Be guided by any inclusion and exclusion terms under the selected code, chapter, block or category heading.
Finally, ASSIGN THE CODE.
Follow carefully any cross-references found in the index.
Refer to the Tabular List (Vol. 1)
Be guided by any inclusion and exclusion terms under the selected code, chapter, block or category heading.
Finally, ASSIGN THE CODE.
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Assign the ICD-10 code for Chronic viral hepatitis C
Example:
Answer: Lead term: Hepatitis
-viral--chronic
---type
----C B18.2
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PhilHealth Circular Number 27 series of 2003
PhilHealth Circular Number 27 series of 2003
“ All claims with no ICD-10 codes, incorrect codes/and or ambiguous ICD-10 codes shall NO LONGER BE DENIED but shall be returned to the accredited health care provider (RTH) on the ground of non-compliance with the correct ICD-10 codes ”
“ All claims with no ICD-10 codes, incorrect codes/and or ambiguous ICD-10 codes shall NO LONGER BE DENIED but shall be returned to the accredited health care provider (RTH) on the ground of non-compliance with the correct ICD-10 codes ”
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Categories ranged from G00-G99
67 of the 100 available categories have been used
There are 11 blocks within this Chapter.
There are 16 asterisk categories. Most of them are result of infectious conditions, as well as neurological conditions resulting from other diseases and conditions
G00-G09 block classifies diseases where the nerve tissue is attacked by various organisms
Nervous SystemNervous System
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Meningitis is usually due to infection and is classified by a combination of a dagger code for Chapter 1 and an asterisk code from G01 or G02 to provide more information
G09(Sequelae of inflammatory diseases of central nervous system) would be listed as a secondary code with the sequelae itself being listed as the main condition
It should be noted that seizures and convulsions NOS are coded R56.8 and are not considered epilepsy unless the term “epilepsy” is specifically used
Nervous SystemNervous System
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ICD-10ICD-10G45.9 : TIA (O)G45.0 : vertebrobasilar insufficiency (O)
I67.9 : CVA, unspecified (C)
I66.9 : CVA, cardioembolic (D)I61.9 : CVA, hemorrhagic (D)I63.9 : CVA, thrombotic infarct (D)
G45.9 : TIA (O)G45.0 : vertebrobasilar insufficiency (O)
I67.9 : CVA, unspecified (C)
I66.9 : CVA, cardioembolic (D)I61.9 : CVA, hemorrhagic (D)I63.9 : CVA, thrombotic infarct (D)
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MORPHOLOGY OF NEOPLASMS:
The classification of morphology of neoplasms (pp. 1177-1204) is used as an additional code to
classify the morphological type for neoplasms
S
M
B
Site
Morphology
Behavior
C00 - D48
M8000 – M9989
/0, /1, /2, /3, /6
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ICD-10ICD-10
C71.9, M9400/3C71.9, M9400/3
• Neoplasm of brain
• Astrocytoma
• Malignant
• Neoplasm of brain
• Astrocytoma
• Malignant
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ICD-10ICD-10
D32.1, M9530/0D32.1, M9530/0
• Neoplasm of spinal meninges
• Meningioma NOS
• Benign
• Neoplasm of spinal meninges
• Meningioma NOS
• Benign
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ICD-10ICD-10
C50.9, M8010/3
C71.2, M8010/6
C50.9, M8010/3
C71.2, M8010/6
1. Breast carcinoma, primary
2. Metastatic carcinoma, temporal lobe
1. Breast carcinoma, primary
2. Metastatic carcinoma, temporal lobe
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Additional Tips for Better Payment
1. Eliminate down coding by providing complete descriptions
2. Rank procedures by order of importance
3. Don’t send documents not required
4. Submit claims promptly and frequently
5. Complete forms ASAP
6. Fill in all blanks. Type NA
7. Make it a practice to follow up with Claims Dept.
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ICD-10ICD-10
G96.1 : Disorders of meninges, unspecified (B)
G00.9 : Bacterial meningitis (C)
G04.2 : bacterial meningo-encephalitis (D)
G96.1 : Disorders of meninges, unspecified (B)
G00.9 : Bacterial meningitis (C)
G04.2 : bacterial meningo-encephalitis (D)
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UpdatesUpdates
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Circular 11, 2007Circular 11, 2007
Code Descriptive Terms RVU
99256 Inpatient consultation for a new or established patient which requires: an expanded focused history, examination and medical decision making. It is requested by another physician or appropriate source; the consultant advises the requesting physician about the management of a specific problem including follow up care for 90 days after the procedure
40
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Circular 11, 2007Circular 11, 2007– Preoperative medical evaluation is a
service provided by a physician whose opinion or advice is requested by another physician regarding evaluation and/or management of a specific medical problem which might affect the patient’s ability to undergo a procedure or might influence the outcome of the procedure
– Preoperative medical evaluation is a service provided by a physician whose opinion or advice is requested by another physician regarding evaluation and/or management of a specific medical problem which might affect the patient’s ability to undergo a procedure or might influence the outcome of the procedure
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Circular 11, 2007Circular 11, 2007
• Qualified physicians who can claim for this service:– Family medicine
– Internal Medicine
– Neurology
– Pediatrics
• Qualified physicians who can claim for this service:– Family medicine
– Internal Medicine
– Neurology
– Pediatrics
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Circular 11, 2007Circular 11, 2007
• Applicable only while the patient is admitted
• Preoperative medical evaluation given on an outpatient basis will not be compensated
• Applicable only while the patient is admitted
• Preoperative medical evaluation given on an outpatient basis will not be compensated
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Circular 11, 2007Circular 11, 2007
• Service is applicable only if surgery is accomplished within the same admission period.– If surgery is deferred no payment
• But may claim PF based on daily visits subject to allowable amount per hospital admission
• Service is applicable only if surgery is accomplished within the same admission period.– If surgery is deferred no payment
• But may claim PF based on daily visits subject to allowable amount per hospital admission
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Circular 11, 2007Circular 11, 2007
• In filing for claims, a copy of the consultation/clearance form with the corresponding assessment and recommendation must be attached
• In filing for claims, a copy of the consultation/clearance form with the corresponding assessment and recommendation must be attached