Question & AnswerQ&A (PHIC PHILHEALTH CIRCULAR NO. 07, S. 2004)
Keratomilieusis, radial keratotomy, and keratoplasty performed solely for refractive error compensation or as a substitute for optometric services (e.g., eye glasses, contact lenses, or other prosthetic devices) are excluded from PhilHealth coverage and deemed non-compensable.
These procedures are covered when performed to treat corneal lesions and to rehabilitate post-operative surgically induced astigmatism and/or anisometropia. Other indications may also be reimbursed after evaluation by the Peer Review Committee.
Claims must be submitted with a fully accomplished PhilHealth Claim Form 3 or a copy of the Clinical Abstract. The surgeon must document the indication for surgery through history and physical examination findings, and operating room records should support the indications.
Claims with incomplete requirements shall not be processed and will be returned to the hospital for completion.
The codes and RVUs are: - 65710: Keratoplasty (lamellar) - 140 RVU - 65730: Penetrating keratoplasty (except in aphakia) - 160 RVU - 65750: Penetrating keratoplasty (in aphakia) - 170 RVU - 65755: Penetrating keratoplasty (in pseudophakia) - 170 RVU - 65760: Keratomileusis (including LASIK) - 100 RVU - 65771: Radial keratotomy - 60 RVU.
The circular took effect 15 days following its publication on February 12, 2004.
The Peer Review Committee evaluates claims for these procedures that are not solely for refractive error correction or substitution of optometric services to determine if reimbursement is appropriate.
No, such claims are excluded from coverage as these procedures are considered substitutes for optometric services.
All other PhilHealth Circulars consistent with the provisions of Circular No. 07, s. 2004 remain in full force and effect.