REVISED CASE TYPE CLASSIFICATION FOR 2009

Pursuant to the approved PhilHealth Board Resolution Number 1208
series of 2009 that aims to update and rationalize the current case type
classification to make benefits more responsive to the members’ needs,
the following clarification and guidelines on the revised case type
classification are hereby issued:

1. Case type is an assessment of complexity of illness assigned to a
case after discharge. It is measured on a four (4) scale system, from A
to D, with case type A being the least complex and case type D as the
most severe.

         

Case Type	Severity	Example
A B C D	Simple Moderate Severe Extremely severe	Upper respiratory tract infection (J06.9) Status asthmaticus (J46) End stage renal disease (N18.0) Deep intracerebral haemorrhage (I61.0)

2. ICD-10 codes considered as case types A, B, C and D are listed in Annex^[*] A, B, C and D, of this Circular.

3. All ICD-10 codes are assigned with corresponding fixed case
types. Hence, all claims submitted to PhilHealth, except those paid
through case payment shall be paid based on the case type of primary
illness.

4. Considering the severity of some illnesses/conditions, modifications in case type assignment may be considered for the
following illness/condition:

a. Cases/conditions considered for automatic upgrade of case type

Illness or Condition	Upgraded to Case Type
Conditions requiring transfusion of blood or blood products	B
Pneumonia
Community-acquired pneumonia III, moderate risk (adult)	B
Pediatric community-acquired pneumonia, moderate risk (PCAPC)	B
Community-acquired pneumonia IV, high risk (adult)	C
Pediatric community-acquired pneumonia, high risk (PCAPD)	C
Malignant neoplasm
Cancer with metastasis	C
Chemotherapy session for neoplasm	C
Radiotherapy session	C
Dialysis session i.e. peritoneal dialysis and hemodialysis	C
In the event of death regardless of illness or condition	D

b. For the following illness/condition, the corresponding case type
shall be considered applicable, provided the diagnosis and ICD-10 code
are clearly stated in the claim form.

Description	Case Type
Chronic respiratory insufficiency	B
Multiple Drug Resistant Tuberculosis confirmed by culture	B
Nosocomial pneumonia	B
Multiple organ failure	C

GENERAL RULES FOR CASE TYPING

A. Medical

1. For coding and reimbursement of medical claims, case type will
be based on the ICD-10 of the primary illness or main condition.The primary illness or main condition is
the condition identified at the time of discharge as being the main
reason for the patient’s confinement, whether it is for receiving care
or for investigation of a current illness or injury (please see
PhilHealth Circular No. 4 s. 2002).

Example 1:

Final Diagnosis	ICD-10 Code	Case Type
Hypertension	I10.9	A
Acute pyelonephritis (Main condition)	N10	B
The final case type for this example is B.

Example 2:

Final Diagnosis	ICD-10 Code	Case Type
End stage renal disease (ESRD)	N18.0	C
Acute pharyngitis (Main condition)	J02.9	A
The final case type for this example is A.

2. In cases wherein the hospital claimed for a lower
reimbursement, PhilHealth shall reimburse to the member within the
amount of the remaining benefit, provided the claim is supported by an
Official Receipt (OR) and Statement of Account (SoA) issued by the
hospital.

3. For cases wherein there is a discrepancy between the final
diagnosis and the management based on part three (III) and four (IV) of
the Claim Form 2, PhilHealth may return the claim to the hospital with
request for a properly accomplished PhilHealth Claim Form 3 and other
appropriate documents e.g., copy of clinical chart, laboratory result,
radiology result and other ancillary procedures, complete clinical
abstract deemed necessary for proper evaluation.

4. For claims wherein the member or hospital request for a higher
case type other than those specified in this circular, PRO – Benefit
Administrative Sections may refer such requests to the Quality Assurance
Committee (QAC) for their evaluation and recommendation. For such
claims, it is reiterated that the complete diagnosis and its applicable
ICD 10 code should be clearly stated in the PhilHealth Claim Form 2 and
a properly accomplished PhilHealth Claim Form 3 should be submitted.

B. Surgical

1.For claims with surgical procedure/s and other services, the case
type shall be based on the corresponding Relative Value Unit (RVU)
assigned to the procedure.

Case Type	RVU	Example
A	80 and below	Simple repair of wound (RVU 10)
B	81 up to 200	Appendectomy (RVU 100)
C	201 up to 500	Whipple-type procedure (RVU 450)
D	501 and above	Surgery intracranial aneurysm (RVU 600)

2. For claims with two (2) or more surgical procedure/s (multiple
surgeries), the case type shall be based on the procedure with the
highest RVU.

Example 3:

Procedure	RVU	Case Type
Excision of breast lesions with frozen section	25	A
Modified radical mastectomy	150	B
Pathology consultation with frozen section, 1 block	20	A
The final case type for this example is B.

3. In cases where the case type for the medical diagnosis and the
surgical procedure are different, the higher case type shall
predominate.

Example 4:

	Case Type
Diagnosis: End stage renal disease (ICD 10 code = N18.0) Procedure done: Hemodialysis (RVU 10)	C A
The final case type for this example is C.

Example 5:

	Case Type
Diagnosis: Acute appendicitis without perforation (ICD 10 code = K35.9) Procedure done: Appendectomy (RVU 150)	A B
The final case type for this example is B.

C. Other Rules

1. For case type D

a. It is reiterated that all claims with
primary illness/condition classified as case type D shall be required
submission of PhilHealth Claim Form 3 or Clinical Abstract for proper
evaluation and assessment. If PhilHealth Claim Form 3 or Clinical
Abstract is not attached in the claim, it shall be returned to the
hospital for completion.

b. For multiple surgical procedures wherein one procedure has an
RVU of 501 and above, only the procedure above RVU 501 will use the
peso conversion factor (PCF) specific for case type D (PCF of 80).
Computation of professional fee for other procedures below 501 will use
the baseline PCF of 40 depending on the tier category of the doctor.

Example 6:

	Case Type
Diagnosis: Deep intracerebral haemorrhage (I61.0) Procedure done: Cutdown (RVU 10) performed by a surgeon	D A
The final case type for this Example is D, however the computation of PF for cutdown will be based on baseline PCF of 56 (RVU 10 x PCF 56 = PF of 560).

c. It is reiterated that benefits for case type D can only be
paid for patients admitted in Level 3 and 4 (tertiary) hospitals. Case
type D in Level 1 (primary) and 2 (secondary) hospitals shall be paid as
case type B and C, respectively.

d. For medical conditions classified as case type D payment of
doctor’s daily visit will depend on the rates provided for case type D.

2. For primary hospitals

a. For all cases classified as case type C and D the maximum benefit is still based on case type B.

b. Claims for Level 1 (primary) hospitals are still required to
submit Claim Form 3 or Clinical Abstract except for claims paid thru
case payment e.g., NSD, BTL, Vasectomy, etc.

This Circular shall be applicable to all admissions effective July 1, 2009.

All other provisions and issuances inconsistent with this circular are hereby repealed, modified and amended accordingly.

Please be guided accordingly.

Adopted: 20 April 2009

(SGD.) DR. REY B. AQUINO
President and CEO

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^[*] Text Available at Office of the National Administrative Register, U. P. Law Complex, Diliman, Quezon City.