MI 224: Standards used in PhilHealth

PowerPoint Presentation

Roy o. Dahildahil, bsph, RMTMI 224 Coding, Classification, and Terminology in Medicine@rdahildahil_ | #ISKOMULI #Philhealth #MSHI2017 #MI224

1

The Story

@rdahildahil_ | #ISKOMULI #Philhealth #MSHI2017 #MI224

2

The StoryVideo courtesy of teamphilhealth@rdahildahil_ | #ISKOMULI #Philhealth #MSHI2017 #MI224

3

HISTORYBegan in early '60s Call to serve the rural indigentsPhilippine Medical AssociationProject MARIAPrioritize aid to communities in need of medical assistancePrecursor for the Medical Care Plan1969 - Republic Act 6111: Philippine Medical Care Act of 1969 was signed by President Ferdinand E. Marcoswww.philhealth.gov.ph


PhilHealth President 1995 Jose FabiaTHE call to serve the rural indigents echoed since the early '60s when the Philippine Medical Association introduced the MARIA Project which prioritized aid to communities in need of medical assistance.valuable precursor to the Medicare program, from which a medical care plan for the entire Philippines was create

August 4, 1969, Republic Act 6111 or the Philippine Medical Care Act of 1969 was signed by President Ferdinand E. Marcos which was eventually implemented in August 19714

Philippine Medical Care ActThe main purposes and objectives of this Act are:

Extension of medical care to all residents in an evolutionary way within our economic means and capability as a nation;Providing the people of the country a practical means of helping themselves pay for adequate medical care; To establish a Medical Care Commission. The Philippine Medical Care Commission (PMCC) was tasked to oversee the implementation of the program which went for almost a quarter of a centurywww.philhealth.gov.ph


PhilHealth President 1995 Jose FabiaTHE call to serve the rural indigents echoed since the early '60s when the Philippine Medical Association introduced the MARIA Project which prioritized aid to communities in need of medical assistance.valuable precursor to the Medicare program, from which a medical care plan for the entire Philippines was create

August 4, 1969, Republic Act 6111 or the Philippine Medical Care Act of 1969 was signed by President Ferdinand E. Marcos which was eventually implemented in August 19715

HISTORY1990s - vision of better, more responsive government health care program Public clamor for a comprehensive health insuranceHouse Bill 14225 and Senate Bill 01738RA 7875 National Health Insurance Act of 1995 signed by P. Fidel V. RamosCreation of Philippine Health Insurance Corporation (PhilHealth)Social health insurance to Filipinos in 15 yearswww.philhealth.gov.ph


In the 1990s, a vision for a better, more responsive government health care program was prompted by the passage of several bills that had significant implications on health financing. The public's clamor for a health insurance that is more comprehensive in terms of covered population and benefits led to the development of House Bill 14225 and Senate Bill 01738 which became The National Health Insurance Act of 1995 or Republic Act 7875, signed by President Fidel V. Ramos on February 14, 1995. The law paved the way for the creation of the Philippine Health Insurance Corporation (PhilHealth), mandated to provide social health insurance coverage to all Filipinos in 15 years' time.6


7

IRR SECTION 43: Benefits of Members and their Dependents Confined Abroad

[] a. Official receipt or any proof of payment and/or statement of account from the health care institution where the member/dependent was confined; and,b. Certification of the attending physician as to the final diagnosis, period of confinement and services rendered.

The benefits to be granted shall be paid to the member in the equivalent local rate based on the Level Three (3)hospital category with the applicable case-rate payment.


8

In order to address the problem where providers do not agree with specific provisions of issuances, i.e. the rates paid for services renderedRelative Value Scale (RVS)


9

History of RVS in the PhilHealthEarly 90sUSAID-funded a study through PhilHealths Health Finance Development Project to update and revise the 1972 Relative Value Scale1995The 1995 RVS was completedImplementation for the 1995 RVS began and was used as the basis for compensation of professionals.

Relative Value Scale (RVS)PhilHealth Board Resolution No. 430 s. 2001Standardize payables i.e. physicians are paid an amount related to the procedures complexity


11

ICD-10reimbursable medical conditions

Sample form

Relative Value Scale (RVS)systematic listing of surgical, medical and diagnostic procedures, and services, and their corresponding 5 digit code and Relative Value Unit (RVU) mostly lifted, with permission, from the Current Procedural Terminology (CPT) of the American Medical Association


descriptions of procedures and the codes used in the book are mostly lifted, with permission, from the Current Procedural Terminology (CPT) of the American Medical Association

The aim of RVS is to attach a relative monetary value to each CPT codeEach procedure or service is identified with a five-digit code (insert screen cap of CPT below)

14

Relative Value Scale (RVS)


listing of reimbursable procedures with their corresponding Relative Value Unit (RVU) and code

What is the format of the terminology?

The RVS 2010 uses a terminology for procedures such that the descriptions are stand-alone or complete by themselves. However, for some procedures, their descriptions are not printed in their entirety, particularly, in the case of those having the same lead terms and listed successively. These similar procedures are laid out such that the common lead term is not repeated on every procedure entry, but rather, placed as a heading (in bold letters) to be considered part of all the indented entries (modifiers) below it.

15

RVUs are determined based on the difficulty of the procedure

Compensation is computed by multiplying the RVU by the peso conversion factor (PCF)Relative Value Scale (RVS)(Asia Pacific Observatory on Health Systems and Policies, 2011)


16


Case typing1. Surgical procedures shall be classified as follows:a. case type A: procedures with RVU of 80 and belowb. case type B: procedures with RVU of 81-200c. case type C: procedures with RVU of 201-500d. case type D: procedures with RVU of 501 and abovee. for multiple surgical procedures, case type shall be based on the procedure with the highest Relative Unit Value (RVU).2. For multiple surgical procedures, case type shall be based on the procedure with the highest Relative Value Unit (RVU).3. In situations where the case type for the surgical procedures and medical diagnoses are not consistent, the higher case type shall prevail.

17

ExampleSplenectomy (38100):Total: RVU x PCF = 160 x 40 = 6,400Partial: RVU x PCF = 150 x 40 = 6,000

Relative Value Scale (RVS)Additions were included by PhilHealth for the reason that these procedures are deemed reimbursable.


19


Operating room fee

20

Computation


PhilHealth Circular No. 2 s. 2001

21


Surgeons and Anesthesiologists fee

22


Control procedures

23

CircularsIn 2008, Quality Assurance Committee was formedConsolidated functions of the Peer Review Committee and the RVU Oversight CommitteeComposed of representatives from the medical specialty societies, Board of Medicine, Professional Regulation Commission (PRC), and the Philippine Hospital Association (PHA). review and update the existing Relative Value Scale (RVS) Amendments to the RVS are continuously updated through PhilHealth Circulars


24

Important CircularsCircular No. 03 s-2003 - Additional List Of Compensable Surgical Procedures And Services In Relative Value Scale 2001Circular No. 19, s-2006 - Addendum to the Compensable Procedures in the Relative Value Scale (RVS) 2001Circular No. 35, s-2006 - Case Rate Codes for claimsCircular No. 02 s-2007 - Amendment to RVS Coding of Laparoscopic AND Other Procedures


25


Updates

26


Maraming Salamat!

27

MI 224: Standards used in PhilHealth

Health & Medicine

Transcript of MI 224: Standards used in PhilHealth