Z Benefit Package Rates for Coronary Artery Bypass Graft Surgery, Surgery for Tetralogy of Fallot, Surgery for Ventricular Septal Defect and Cervical Cancer

February 6, 2013

PHILHEALTH CIRCULAR NO. 002-13

 

I. Rationale

Pursuant to PhilHealth Board Resolution No. 1629 s. 2012, and PhilHealth Circular No. 29, s. 2012, "Governing Policies on PhilHealth Benefit Package for Case Type Z", the following are the services and rates for coronary artery bypass graft surgery (CABG), surgery for Tetralogy of Fallot (TOF), surgery for ventricular septal defect (VSD), and cervical cancer.

The illnesses and their risk classification included are as follows:

1. Standard Risk Elective Surgery for: Coronary Artery Bypass Graft (CABG), Total Correction of Tetralogy of Fallot (TOF), and Surgery for Ventricular Septal Defect (VSD);

2. Cervical Cancer Stage I to IIIB;

These conditions were chosen based on current evidence that quality treatment significantly increases survival rates and quality of life. Moreover, valid information for these conditions is readily available.

II. Rules for Identified Case Type Z

A. Only newly diagnosed cases of cervical cancer shall be covered under the benefit package. For coronary artery bypass graft surgery, total correction of TOF and closure of VSD, only those cases that strictly fulfill the selections criteria shall be covered; ISDCaT

B. Beginning January 1, 2013, all members availing of the Z Benefit shall be required a 3-year lock-in membership prior to availment of the benefit. The lock-in membership does not apply to lifetime members and sponsored program members;

C. Pre-authorization from PhilHealth based on the approved selections criteria per specific Z condition shall be required prior to availment of services. All requests for pre-authorization shall be completely accomplished by the contracted hospital and submitted to the Head of the Regional Benefits Administration Section for approval or disapproval;

D. The diagnosis during pre-authorization shall be the basis for reimbursement;

E. No balance billing (NBB) policy shall be applied for eligible sponsored program members and their qualified dependents. Negotiated fixed co-pay shall be applied for eligible non-sponsored members and their qualified dependents. In no instance shall the fixed co-pay exceed the package rate;

F. The professional fees for surgery of CABG, TOF and VSD shall be 20% of the package rate; the professional fees for cervical cancer is 15% of the package rate;

G. Patients enrolled in the Z benefit will be deducted a maximum of five (5) days from the 45 days annual benefit limit regardless of the actual length of stay of the patient in the hospital. Such deductions shall be made on the current year and no deductions shall be made in the succeeding year. In cases where the remaining annual benefit limit is less than five (5) days, the member shall remain eligible to avail of the Z Benefit, provided that premiums are updated;

H. Any complication/s arising during the hospital confinement for the particular Z condition shall be part of the package;

I. Hospital confinements due to other causes as determined by the primary condition shall be paid separately; cHITCS

J. All rates are inclusive of government taxes;

K. Rules on pooling of professional fees for government facilities shall apply;

L. In cases when the patient expires anytime during the course of treatment or the patient is lost to follow up, the payment schedule for the specific treatment phase shall still be released as long as the patient has received the scheduled treatment. The remaining tranche shall not be paid;

M. All mandatory and other services of the specific Z conditions shall be given according to the approved clinical pathways, treatment protocols, clinical guidelines and other standards of care.

III. Case Type Z

A. Elective Surgery for Standard Risk Coronary Artery Bypass Graft

1. The package code is Z005 which includes the following ICD-10 and RVS codes:

ICD10	Management/Procedures	RVS Codes
I20	Coronary Artery Bypass Graft Surgery	33510-33516
I25		33517-33523
		33533-33536
		33572

2. The package rate shall be P550,000 for the entire course of treatment.

3. Selections criteria for CABG: SHTcDE

a. Signed Member Empowerment (ME) Form

b. Age 19-70 years

c. Stable Coronary Artery Disease requiring ELECTIVE ISOLATED Coronary Artery Bypass Graft Surgery (CABG) with indication based on coronary anatomy, symptom severity, LV function, and/or viability tests; non-invasive testing completed and discussed with patient

d. Current Medical Status:

i. Not in severe decompensated heart failure (NYFC IV)

ii. Not with severe angina (CCS Class III)

iii. No other cardiac/vascular procedures/interventions planned to be done with CABG during the admission

e. Past History:

i. No previous cardiac surgery such as CABG, valve surgery, etc.

ii. No previous transcutaneous cardiac intervention such as coronary angioplasty or stenting

f. ONLINE EUROSCORE II and/or STS scoring predictive of low mortality risk (< 5%)

4. The approved clinical pathway for CABG shall reflect the mandatory and other services as indicated in the table below. aSEHDA

 

Mandatory Services	Other Services
1.	Pre-op lab tests: CBC,	1.	Additional laboratory tests as needed,
	platelet count, blood typing,		intra-operatively or postoperatively e.g.,
	Na, K, Mg, Calcium, FBS,		ankle-brachial index, carotid duplex scan;
	BUN, creatinine, chest x-ray		postoperative CBC, platelet count, APTT,
	(PA/lateral), 12-lead ECG,		PTPA-INR, FBS, Na, K, Mg, Calcium,
	room air ABG		BUN, creatinine, TPAG, urinalysis,
			chest x-ray (portable/AP/lateral), 12-lead
2.	Preoperative antibiotic		ECG, ABG, 2DED, TEE, as indicated
	prophylaxis (ex. vancomycin
	and amikacin)	2.	Postoperative antibiotics if indicated (IV
			and oral)
3.	Medications, as indicated,
	such as beta blocker, statin	3.	Treatments, as indicated, such as:
	ACE inhibitor or ARB, ASA
			a.	Incentive spirometry
4.	Blood support — screening
	and blood products, as		b.	VTE Prophylaxis with compression
	needed			stockings/intermittent pneumatic
				compression/intravenous/subcutaneous
5.	Pre-operative evaluation/CP			heparin, LMWH, fondaparinux
	clearance
			c.	Nebulization with medications such as
6.	Open Heart Surgery under			beta agonist + steroid or salbutamol/
	general anesthesia			pulmonary physiotherapy
7.	Immediate postoperative		d.	Blood glucose monitoring
	care at surgical ICU
			e.	Wound dressings/wound care
8.	Continuing postoperative
	care at regular room	4.	Other medications, as indicated, such as:
			clopidogrel, digoxin, furosemide IV or oral,
9.	Cardiac Rehabilitation		amiodarone, vasopressors (dopamine,
			levophed, epinephrine infusion drip),
			inotropic drugs (dobutamine infusion
			drip),vasodilator (NTG or Isoket or
			Nicardipine), insulin regimen, oral
			hypoglycemic drugs, proton pump
			inhibitor/antacid, pain relievers/analgesics,
			sedatives/anxiolytics, magnesium chloride,
			calcium gluconate, potassium chloride,
			lactulose/stool softeners
		5.	Pulmonary care, as indicated, such as
			ventilator support; nebulization, with beta
			2 agonist/combination with steroid
		6.	Other specialty services as needed, such
			as pulmonology, nephrology, neurology,
			infectious disease, etc.

5. The payment for this package shall be Five Hundred Fifty Thousand pesos (P550,000) for the complete course of care which shall be given in two (2) tranches as follows:

Mode of	Amount	Filing Schedule
Payment
1st tranche	P500,000	Within 60 days after discharge from surgery
2nd tranche	P50,000	Within 60 days after the first follow-up, one
		week post-discharge (to check the vital signs
		and hemodynamic status, operative site
		wound care, continuation of cardiac
		rehabilitation OPD phase of program)

 

B. Surgery for Total Correction of Tetralogy of Fallot

1. The package code is Z006 which includes the following ICD-10 and RVS codes: caIACE

ICD10	Management/Procedures	Codes
Q21.3	Total Correction of Tetralogy	33692, 33694, 33697
	of Fallot

2. The package rate shall be P320,000 for the entire course of treatment.

3. Selections criteria for surgery for TOF:

a. Signed Member Empowerment (ME) Form

b. Age: 1 to 10 years + 364 days

c. 2D Echocardiogram:

i. Pulmonary artery size

• McGoon's index (Aorta/Pa ratio) > 1.5

• Z score Pulmonary Valve Annulus: Acceptable if z score/BSA: > 3 or better

• Z score peripheral PA's: Acceptable if > 2 or better

ii. Absence of major aortopulmonary collateral arteries (MAPCAs)

d. If cardiac catheterization/hemodynamic study available: PA size: adequate by Z score standards/BSA

e. No previous cardiac surgery (Blalock Taussig Shunt)

f. Functional Class I-II TICaEc

g. No co-morbid factors, such as any of the ff:

i. Preoperative seizures

ii. Brain abscess

iii. Stroke events

iv. Bleeding disorders

v. Infective endocarditis

vi. Other congenital anomalies

4. The approved clinical pathways for TOF shall reflect the mandatory and other services as indicated in the table below:

Mandatory Services	Other Services
1.	Pre-op labs: CBC platelet count, Na,	1.	Postoperative antibiotics as
	K, Ca, Mg, PT PTT, creatinine		indicated (intravenous and oral)
2.	Pre-operative clearance/CP clearance	2.	Other meds, as indicated, such
			as oral 2nd gen cephalosporins
3.	Open heart surgery for total correction		and oral ciprofloxacin, if
	of TOF under general anesthesia		necessary
4.	Post-op labs: PT, PTT	3.	Pulmonary care, when needed,
			such as ventilator support,
5.	Pulmo labs: ABG pre-op, ABG		nebulizations, etc.
	lactate electrolytes, capnograph
		4.	Other specialty services as
6.	Radiology: chest x-ray		needed, such as pediatric
			infectious disease, etc.
7.	Non-invasive labs, as indicated:
	IOTEE, post-op Echo-CFDS, 15-lead
	ECG
8.	Other labs, as indicated: drug assay
9.	Pre-op meds: antibiotic prophylaxis
	(ex. vancomycin, amikacin),
	methylprednisolone
10.	Other meds as indicated: dopamine,
	dobutamine, milrinone, furosemide
	IV, calcium gluconate, digoxin (oral),
	furosemide oral, ibuprofen, captopril
11.	Blood support — screening & blood
	products
12.	Pedia Care Rehabilitation (4 sessions)

 

5. The payment for this package shall be Three Hundred and Twenty Thousand pesos (Php320,000) for the complete course of care which shall be given in two (2) tranches as follows: EScHDA

Mode of	Amount	Filing Schedule
Payment
1st tranche	P270,000	Within 60 days after discharge from surgery
2nd tranche	P50,000	Within 60 days after completion of
		Rehabilitation Exercise Sessions (3rd-4th
		session in the first week post-op)

 

C. Surgery for Closure of Ventricular Septal Defect

1. The package code is Z007 which includes the following ICD-10 and RVS codes:

ICD10	Management/Procedures	RVS Code
Q21	Closure of Ventricular Septal	33681
	Defect with or without patch

2. The package rate shall be P250,000 for the entire course of treatment.

3. Selections criteria for surgery for VSD:

a. Signed Member Empowerment (ME) Form

b. Age: 1 to 5 years + 364 days

c. 2D-echocardiography

i. Isolated VSD perimembranous, subaortic or subpulmonic

ii. No combined shunts such as atrial septal defect or patent ductus arteriosus or atrioventricular septal defect EAIcCS

iii. No other associated CHD's: such as coarctation of the aorta, or moderate to severe aortic insufficiency, or moderate to severe pulmonic stenosis

iv. Pulmonary artery pressure: < 50 mmHg or at least 2/3 systolic blood pressure

v. QP QS: > 1.5:1

d. No previous cardiac surgery (PA Banding)

e. Functional Class I-II

f. No co-morbid factors, such as any of the ff:

i. Preoperative seizures

ii. Brain abscess

iii. Stroke events

iv. Bleeding disorders

v. Infective endocarditis

g. No chromosomal abnormalities and other associated congenital defects

4. The approved clinical pathways for VSD shall reflect the mandatory and other services as indicated in the table below.

Mandatory Services	Other Services
1.	Pre-op Labs: CBC Platelet count,	1.	Postoperative antibiotics as
	Na, K, Ca, Mg, PT PTT, creatinine		indicated (intravenous and oral)
2.	Pre-operative evaluation/CP	2.	Other meds, as indicated, such as
	clearance		oral 2nd gen cephalosporins and
			ciprofloxacin, if necessary
3.	Surgery: VSD patch closure under
	general anesthesia	3.	Pulmonary care, when needed,
			such as ventilator support,
4.	Post-op labs: PT, PTT		nebulizations, etc.
5.	Pulmo labs: ABG pre-op, ABG	4.	Other specialty services as needed,
	lactate electrolytes, capnograph		such as pediatric infectious disease,
			etc.
6.	Radiology: chest x-ray
7.	Non-invasive Labs: IOTEE
8.	Pre-op meds: antibiotic prophylaxis
	(ex. vancomycin, amikacin),
	methylprednisolone
9.	Other meds, as indicated: dopamine,
	dobutamine, milrinone, furosemide
	IV, calcium gluconate, digoxin
	(oral), furosemide oral, ibuprofen,
	captopril
10.	Blood support —
	screening and blood products
11.	Pedia Care Rehabilitation (4
	sessions)

 

5. The payment for this package shall be Two Hundred Fifty Thousand pesos (Php250,000) for the complete course of care which shall be given in two (2) tranches as follows: HDAECI

Mode of	Amount	Filing Schedule
Payment
1st tranche	P200,000	Within 60 days after discharge from surgery
2nd tranche	P50,000	Within 60 days after completion of
		Rehabilitation Exercise Sessions (3rd-4th
		session in the first week post-op)

C. Cervical Cancer Chemoradiation with Cobalt & Brachytherapy (Low Dose) or Primary Surgery for Stage IA1, IA2-IIA1

1. The package code is Z008 which includes the following ICD-10 and RVS codes:

ICD10	Management/Procedures	RVS Codes
C53	Histopathology
	Cervical biopsy	57500
	Cone biopsy	57520
	LEEP	57522
	Chemotherapy	96408
	Radiotherapy
	Pelvic Cobalt	77401
	Brachytherapy (low dose) surface,	77761
	interstitial or intracavitary
	For Stage IA1 only:
	Total Extrafascial Hysterectomy with
	or without bilateral salpingoophorectomy	58150
	For stage IA2-IIA1:
	Radical hysterectomy with bilateral
	pelvic lymphadenectomy and paraaortic
	lymph node sampling with or without
	bilateral salpingoophorectomy	58210

 

2. The package rate shall be P120,000 for the entire course of treatment.

3. Selections criteria

a. Signed ME Form

b. No previous chemotherapy

c. No previous radiotherapy

d. No uncontrolled co-morbid conditions

e. Treatment plan from gynecologic oncologist

4. The approved clinical pathways for Cervical Cancer Primary Surgery shall reflect the mandatory and other services as indicated in the table below. cAHDES

Mandatory Services	Other Services
1.	Pre-op/pre-procedure labs, as	1.	Cystoscopy or
	indicated: CBC, platelet count,		proctosigmoidoscopy, if indicated
	blood typing, FBS, creatinine,
	SGOT, SGPT, serum electrolytes,	2.	Other meds as indicated:
	Mg, PT/PTT, AST/ALT,		tranexamic acid, calcium
	urinalysis, ECG, chest x-ray		gluconate, analgesics
2.	Imaging studies, as indicated:	3.	Postoperative antibiotics as
	transvaginal ultrasound, whole		indicated (intravenous and oral)
	abdominal CT scan or MRI
		4.	Support Medications — when
3.	Pre-op/pre-procedure clearance		indicated and needed, such as
			anti-emetics (ex. ramosetron,
4.	Pre-op meds: antibiotic prophylaxis,		granisetron, metoclopramide),
	such as cefoxitin, cefuroxime		G-CSF, hematinics, etc.
5.	Surgery (for Stage IA1 and Stage
	IA2-IIA1) under spinal epidural
	anesthesia
6.	Chemotherapy (ex. cisplatin,
	carboplatin)
7.	Radiotherapy (pelvic cobalt)
8.	Brachytherapy (low dose rate)
9.	Post-op/post-procedure labs:
	CBC with platelet
10.	Blood Support (ex. cross matching,
	screening, processing)

 

5. The payment for this package shall be One Hundred Twenty Thousand pesos (Php120,000) for the complete course of care which shall be given in two (2) tranches as follows:

Mode of	Amount	Filing Schedule
	Payment
1st tranche	P100,000	Within 60 days after discharge from surgery
		or from the last cycle of chemoradiation
2nd tranche	P20,000	Within 60 days after the first follow-up
		without complications. (Pelvic exam done

 

D. Cervical Cancer Chemoradiation with Linear Accelerator & Brachytherapy (High Dose)

1. The package code is Z009 which includes the following ICD-10 and RVS codes: cHSIAC

ICD 10	Management/Procedures	RVS Codes
C53	Histopathology
	Cervical biopsy	57500
	Cone biopsy	57520
	LEEP	57522
	Chemotherapy	96408
	Radiotherapy
	Linear Accelerator	77401
	Brachytherapy (high dose) surface,
	interstitial or intracavitary	77761

2. The package rate shall be P175,000 for the entire course of treatment.

3. Selections criteria

a. Signed ME Form

b. No previous chemotherapy

c. No previous radiotherapy

d. No uncontrolled co-morbid conditions

e. Treatment plan from gynecologic oncologist

4. The approved clinical pathways for Cervical Cancer Chemoradiation shall reflect the mandatory and other services as indicated in the table below. SCHIcT

Mandatory Services	Other Services
1.	Pre-procedure labs, as indicated:	1.	Cystoscopy or
	CBC, platelet count, blood typing,		proctosigmoidoscopy, if indicated
	FBS, creatinine, SGOT, SGPT,
	serum electrolytes, Mg, PT/PTT,	2.	Other meds as indicated:
	AST/ALT, urinalysis, ECG, chest		tranexamic acid, calcium gluconate,
	x-ray		analgesics
2.	Imaging studies: transvaginal	3.	Post-procedure antibiotics as
	ultrasound, whole abdominal CT		indicated (intravenous and oral)
	scan
		4.	Support Medications — when
3.	Pre-procedure clearance		indicated and needed, such as
			anti-emetics (ex. ramosetron,
4.	Pre-procedure meds, as needed:		granisetron, metoclopramide),
	antibiotic prophylaxis such as		G-CSF, hematinics, etc.
	cefoxitin, cefuroxime
5.	Chemotherapy (ex. cisplatin,
	carboplatin)
6.	Radiotherapy (linear accelerator)
7.	Brachytherapy (high dose rate)
8.	Post-procedure labs: CBC with
	platelet
9.	Blood Support (ex. cross matching,
	screening, processing)

 

5. The payment for this package shall be One Hundred Seventy Five Thousand pesos (Php175,000) for the complete course of care which shall be given in two (2) tranches as follows:

Mode of	Amount	Filing Schedule
Payment
1st tranche	P125,000	Within 60 days from the last cycle of
		chemoradiation
2nd tranche	P50,000	Within 60 days after first follow-up without
		complications. (Pelvic exam done)

 

IV. Outpatient Laboratory and Diagnostics

All pre-op/pre-procedure laboratory and diagnostic examinations necessary for surgical clearance or mandatory procedures with official receipts and which are done on an outpatient basis shall be reimbursed by the hospital to the patient once PhilHealth has paid the first tranche payments to the hospital.

V. Claims Filing

All claims shall be filed by the contracted hospitals in behalf of the patient according to the Implementing Guidelines on the Z Benefit Package (PhilHealth Circular 48, s. 2012).

VI. Effectivity

This Circular shall take effect for all approved pre-authorizations starting February 13, 2013. This shall be published in any newspaper of general circulation and deposited thereafter with the Officer of the National Administrative Register, University of the Philippines Law Center.

VII. Annexes (refer to www.philhealth.gov.ph)

1. Pre-authorization checklist and request ACaDTH

a. CABG

b. TOF

c. VSD

d. Cervical Cancer

2. Checklist for Mandatory and Other Services

a. CABG

b. TOF

c. VSD

d. Cervical Cancer

Please be guided accordingly.

 

(SGD.) ENRIQUE T. ONA, MDSecretary of Health

ATTACHMENT

 

Pre-Authorization Checklist

 

 

Pre-Authorization Checklist

 

 

Pre-Authorization Checklist

 

 

Pre-Authorization Checklist

 

 

Pre-Authorization Request for Cervical Cancer

 

 

Tetralogy of Fallot — Elective TOF Repair

 

 

Ventricular Septal Defect — Elective VSD Closure

 

 

Standard Risk Elective

 

 

Standard Risk Elective

 

 

Tetralogy of Fallot — Elective TOF Repair

 

 

Ventricular Septal Defect

 

 

Checklist of Mandatory and Other Services

 

 

Checklist of Mandatory and Other Services

 

 

Checklist of Mandatory and Other Services