Non-Compensable Local Anesthesia and Reimbursement of Anesthetic Agents
- Local anesthesia given through infiltration, drops, spray, or ointment is not compensable as a professional fee.
- Local anesthetic agents (e.g., lidocaine 1% vial) may be reimbursed under drugs and medicines subject to existing guidelines.
Definition and Scope of Monitored Anesthesia Care (MAC)
- MAC involves anesthesiologist-provided care where a procedure is performed under local anesthesia, with or without sedation and analgesia.
- The anesthesiologist continuously monitors vital signs, manages cardiovascular instability, administers and adjusts sedatives, and converts to general anesthesia if needed.
Coverage and Conditions for Reimbursement of MAC Professional Fees
- MAC professional fees are reimbursable only if:
i) The procedure facilitated by MAC is covered by PhilHealth.
ii) Patient clinical conditions justify the need for MAC, including:- Extreme age (under 1 year or over 70 years)
- Cognitive impairments (e.g., mental retardation, autism, dementia)
- Psychological impairments (e.g., schizophrenia, bipolar disorder, PTSD)
- Extreme anxiety disorders
- Systemic diseases such as CAD, COPD, emphysema, ESRD, diabetes, hypertension
- Critically-ill patients
- MAC fees for diagnostic procedures without relative value units (e.g., CT, MRI) are not reimbursed.
- MAC services for cataract surgeries paid by case payment (specific RVS codes) are excluded from coverage.
Documentation Requirements for Claims on MAC and Conscious Sedation
- Claims must be accompanied by:
- Properly accomplished Anesthesia Record.
- PhilHealth Claim Forms.
- Operative Technique documentation.
Effectivity and Continuity of Regulations
- Circular is effective for claims with admission dates from September 1, 2009 onwards.
- Prior issuances inconsistent with this Circular are superseded; others remain effective.
- This Circular intends to standardize the reimbursement process for anesthesia professional fees to ensure clarity and proper payment.