PhilHealth Tidbits: General rules for all surgeries and procedures
Only procedures listed in the RVS 2001 manual shall be compensated. All other procedures not listed in the RVS 2001 shall not be reimbursed unless approved by the Corporation as addendum to the scale. Surgeries and procedures done in primary hospitals shall only be compensated for simple surgical operations (RVU of 30 and below).
Any operation performed beyond the accredited capability of primary hospitals shall be denied except when the same is done in an emergency case. In all surgical procedures done in accredited primary hospitals, the maximum payment for hospital charges drugs/medicines, xrays/ laboratories and operating room) and the surgeon's professional fees, including emergency cases, shall be based on RVU of 30 .
For multiple surgical procedures, case type shall be based on the procedure with the highest RVU.
In situations where the case type for the surgical procedures and medical diagnosis are not consistent, the higher case type shall prevail. All payments for professional fees are governed by the rule of single period of confinement/per availment. All surgeries performed on different dates shall be compensated at their respective value units but the total amount should not surpass the cap set by the Corporation.
Payment for professional fee of the surgeon shall be based on the RVU of the procedure and the existing Peso Conversion Factor (PCF) which is currently set at P40 per RVU.
Any operation with a unit value above four hundred (400) shall be paid the maximum of sixteen thousand (P16,000) pesos. Two and more surgical procedures done in one sitting through a single incision performed by one or more physicians shall be compensated using the procedure with the highest value unit.
Compensation for the listed procedures shall cover the following global surgical services associated with the operation: pre-operative visits before the surgery; intra-operative services that are normally a usual and necessary part of a surgical procedure; post-operative services provided by the surgeon within 90 days of the surgery like dressing changes; local incision care; removal of operative packs, removal of cutaneous sutures, staples, lines, wires, tubes, drains, casts, and splints; removal insertion, irrigation, and removal of urinary catheters; routine peripheral intravenous lines and nasogastric and rectal tubes; and change and removal of tracheostomy tubes; and follow-up visits provided during this time by the surgeon that are related to recovery from the surgery.
The anesthesiologist fee shall be 30% of the surgeon's fee but not to exceed five thousand (P5,000) pesos. The payment for post-surgical pain management is already included in the anesthesiologist's fee.