PHIC PHILHEALTH CIRCULAR NO. 07, S. 2004, February 12, 2004

[ PHIC PHILHEALTH CIRCULAR NO. 07, S. 2004, February 12, 2004 ]

LIMITATIONS AS TO THE AVAILMENT OF KERATOMILIEUSIS, RADIAL KERATOTOMY AND KERATOPLASTY

Pursuant to PhilHealth Board Resolution No. 650, s. of 2004, keratomilieusis, radial keratotomy and keratoplasty performed for refractive error compensation or as a substitute for optometric services (i.e. eye glasses, contact lenses or other prosthetic devices) shall be excluded from PhilHealth Coverage and are deemed non-compensable surgeries or procedures.

However, claims for keratomilieusis, radial keratotomy and keratoplasty performed to treat corneal lesions and to rehabilitate post-operative surgically induced astigmatism and/or anisometropia shall be covered and reimbursed. Other indications that do not merely result in the correction of refractive errors or as a substitute for optometric services may also be reimbursed after due evaluation by the Peer Review Committee.

The following are the codes, descriptive terminologies and RVU assigned for the procedures:

CODE DESCRIPTIVE TERMS

RVU

65710 Keratoplasty (corneal transplant); lamellar 140

65730 Penetrating (except in aphakia) 160

65750 Penetrating (in aphakia) 170

65755 Penetrating (in pseudophakia) 170

65760 Keratomileusis (including LASIK) 100

65771 Radial keratotomy 60

In order to establish the compensability of keratomilieusis, radial keratotomy and keratoplasty, all claims for these procedures must be submitted together with a fully accomplished PhilHealth Claim Form 3 or a copy of Clinical Abstract. The surgeon should document the indication for the surgery through history and physical examination findings. Operating room records should also support the presence of the indications. Claims with incomplete requirements shall not be processed and shall be returned to hospital for completion.

All other Circulars consistent herewith remain in full force and effect.

This circular will take effect 15 days following publication hereof.

Please be guided accordingly.

Adopted: 12 Feb. 2004

(SGD.) FRANCISCO T. DUQUE, MD, MSc

President and CEO