ICD-10 Code Assignments
- All ICD-10 codes have fixed case type assignments detailed in the circular annexes.
- Claims are reimbursed according to the assigned case type of the primary illness, except those under case payment.
Automatic Case Type Upgrades
- Specific conditions trigger automatic upgrade of case type due to illness severity or treatment complexity, such as:
- Blood transfusions upgraded to B
- Moderate to high-risk community-acquired pneumonia upgraded to B or C
- Malignant neoplasm with metastasis, chemotherapy, radiotherapy, dialysis upgraded to C
- Death results in case type D, regardless of diagnosis
- Additional specified conditions and their case types include chronic respiratory insufficiency (B), multiple drug resistant tuberculosis (B), nosocomial pneumonia (B), and multiple organ failure (C).
Medical Case Typing Guidelines
- Primary illness or main condition at discharge determines case type based on ICD-10.
- When multiple diagnoses exist, the main condition dictates the final case type.
- Hospitals reimbursed at lower rates can reimburse members up to remaining benefits with valid receipts.
- Discrepancies in diagnosis and management require additional documentation for proper evaluation.
- Requests for case types differing from specified must be evaluated by the Quality Assurance Committee with complete documentation.
Surgical Case Typing Guidelines
- Case type for surgical claims is based on the highest Relative Value Unit (RVU) procedure performed:
- RVU ≤ 80: Case Type A
- RVU 81–200: Case Type B
- RVU 201–500: Case Type C
- RVU ≥ 501: Case Type D
- For multiple surgeries, the highest RVU determines case type.
- When medical and surgical case types differ, the higher case type prevails.
Rules for Case Type D Claims
- Submission of detailed Claim Form 3 or Clinical Abstract required for evaluation.
- In multiple surgeries where one procedure has RVU ≥ 501, PCF for professional fee differs:
- Procedure ≥ 501 uses case type D PCF (80)
- Other procedures use baseline PCF depending on doctor tier
- Case Type D payments only valid in Level 3 and 4 hospitals; otherwise, downgraded payments apply.
- Doctor’s daily visit fees for case type D follow rates for case type D.
Provisions for Primary Hospitals (Level 1)
- Maximum benefits for case type C and D cases capped at case type B level.
- Claims require submission of Claim Form 3 or Clinical Abstract except for specific case payment treatments.
Implementation and Repeal
- The circular applies to all admissions from July 1, 2009.
- Conflicting provisions and earlier issuances are repealed, modified, or amended accordingly.