Exclusions Based on Patient Safety
- Procedures with RVU of 200 and below but requiring more than 24 hours of confinement (e.g., cesarean section, exploratory laparotomy) are excluded when performed as outpatient services.
- PhilHealth will issue a negative list of additional non-compensable procedures with RVU of 200 and below in subsequent circulars.
- Claims for outpatient services involving surgical procedures or multiple procedures totaling RVU of 201 and above will be disallowed to prioritize patient safety.
Ambulatory Surgical Clinics (ASC) and Benefit Limits
- Ambulatory surgical clinics are treated as analogous to secondary hospitals.
- ASCs are entitled to the same benefit limits as secondary hospitals.
- Each use of ASC counts as one day against the 45-day annual benefit limit provided by PhilHealth.
Coverage of Drugs, Ancillary Procedures, and Operating Room Use
- Only drugs, medicines, and supplies used on the day of surgery are reimbursable.
- Laboratory and ancillary procedures reimbursed only if performed on the day of surgery and deemed necessary, such as intraoperative biopsies.
- Operating room fees reimbursed based on the RVU of the specific surgical procedure.
Professional Fees and Anesthesia
- Surgeon’s professional fee is based on the RVU of the procedure and the Peso Conversion Factor (PCF).
- Anesthesiologist fees for local anesthesia are not covered except when regional nerve block anesthesia is administered.
Extended Stay and Denial of Claims
- Surgical procedures conducted in accredited ASCs with extended stays of more than 24 hours are subject to claim denial.
- This rule ensures adherence to outpatient service definition and patient safety concerns.
Effective Date and Implementation
- Clarificatory rules apply to day surgeries with discharge dates starting December 1, 2002.
- These rules should not be interpreted as introducing new benefits but as clarifications to existing coverage.
- All other PhilHealth rules and guidelines not in conflict with these provisions continue to be in force.
Authority and Issuance
- Issued under PhilHealth Board Resolution No. 487 series of 2002.
- Signed by Francisco T. Duque III, MD, MSc., President and CEO of PhilHealth on October 1, 2002.
This comprehensive framework ensures clear guidelines for reimbursement and patient safety standards in day surgeries for both hospitals and ambulatory surgical clinics under PhilHealth coverage.