Coverage and Reimbursement Exceptions
- These eye surgeries are compensable and reimbursable when performed to treat actual corneal lesions.
- Procedures aimed at rehabilitating surgically induced post-operative astigmatism or anisometropia are also eligible for coverage.
- Additional indications beyond refractive error correction or optometric substitution may be reimbursed subject to the assessment and approval of the PhilHealth Peer Review Committee.
Assigned Procedure Codes and Relative Value Units (RVU)
- The circular specifies procedure codes and corresponding relative value units indicating billing and coverage guidelines:
- Code 65710: Lamellar Keratoplasty (corneal transplant) – RVU 140
- Code 65730: Penetrating Keratoplasty (except in aphakia) – RVU 160
- Code 65750: Penetrating Keratoplasty (in aphakia) – RVU 170
- Code 65755: Penetrating Keratoplasty (in pseudophakia) – RVU 170
- Code 65760: Keratomileusis (including LASIK) – RVU 100
- Code 65771: Radial Keratotomy – RVU 60
Documentation and Claims Requirements
- All claims for keratomileusis, radial keratotomy, and keratoplasty must be filed with a duly accomplished PhilHealth Claim Form 3 or accompanied by a Clinical Abstract.
- The attending surgeon must clearly document the surgical indication using detailed history and physical examination findings.
- Operating room records must corroborate the stated clinical indications.
- Claims lacking these complete documentation requirements will be rejected and returned to the hospital for completion before processing.
Effectivity and Continuity of Provisions
- This circular's provisions became effective 15 days after its publication date.
- Existing PhilHealth circulars that are consistent with these rules remain valid and enforceable.
The circular aims to clearly delineate reimbursable conditions for specialized corneal surgeries to prevent abuse of PhilHealth funds by excluding elective procedures substituting for optical aids, while allowing coverage for medically necessary interventions.