In order to address the problem where providers do not agree with specific provisions of issuances, i.e. the rates paid for services rendered Relative Value Scale and ICD 10 was implemented by PhilHealth. Know more about standards used in PhilHealth here. View video presentation here: https://youtu.be/xmZPj6Xw5lo

1. Roy o. Dahildahil, bsph, RMT
MI 224 Coding, Classification,
and Terminology in Medicine
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2. The
Story
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3. The Story
Video courtesy of teamphilhealth
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4. HISTORY
• Began in early '60s
• Call to serve the rural indigents
• Philippine Medical Association
• Project MARIA
• Prioritize aid to communities in need of medical
assistance
• Precursor for the Medical Care Plan
• 1969 - Republic Act 6111: Philippine Medical Care
Act of 1969 was signed by President Ferdinand E.
Marcos
www.philhealth.gov.ph
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5. Philippine Medical
Care Act
The main purposes and objectives of this Act are:
a) Extension of medical care to all residents in an
evolutionary way within our economic means and
capability as a nation;
b) Providing the people of the country a practical means
of helping themselves pay for adequate medical care;
c) 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 century
www.philhealth.gov.ph
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6. HISTORY
• 1990s - vision of better, more responsive
government health care program
• Public clamor for a comprehensive health insurance
• House Bill 14225 and Senate Bill 01738
• RA 7875 National Health Insurance Act of 1995
signed by P. Fidel V. Ramos
• Creation of Philippine Health Insurance Corporation
(PhilHealth)
• Social health insurance to Filipinos in 15 years
www.philhealth.gov.ph
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8. 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.
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9. In order to address the problem where providers do
not agree with specific provisions of issuances, i.e.
the rates paid for services rendered
Relative Value Scale
(RVS)
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10. History of RVS in the
PhilHealth
Early 90’s
• USAID-funded a study through PhilHealth’s Health
Finance Development Project to update and revise
the 1972 Relative Value Scale
1995
• The 1995 RVS was completed
• Implementation for the 1995 RVS began and was
used as the basis for compensation of
professionals.

11. Relative Value Scale (RVS)
• PhilHealth Board
Resolution No.
430 s. 2001
• Standardize
payables
• i.e. physicians
are paid an
amount related
to the
procedure’s
complexity
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12. ICD-10
• reimbursable
medical
conditions

13. Sample form

14. 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
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15. Relative Value Scale (RVS)
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• listing of reimbursable procedures with their
corresponding Relative Value Unit (RVU) and code

16. • 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)
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17. @rdahildahil_ | #ISKOMULI #Philhealth #MSHI2017
Case typing
1. Surgical procedures shall be classified as follows:
a. case type A: procedures with RVU of 80 and below
b. case type B: procedures with RVU of 81-200
c. case type C: procedures with RVU of 201-500
d. case type D: procedures with RVU of 501 and above
e. 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.

18. Example
Splenectomy (38100):
Total: RVU x PCF = 160 x 40 = 6,400
Partial: RVU x PCF = 150 x 40 = 6,000

19. Relative Value Scale (RVS)
• Additions were
included by
PhilHealth for the
reason that these
procedures are
deemed
reimbursable.
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20. @rdahildahil_ | #ISKOMULI #Philhealth #MSHI2017
Operating room fee

21. Computation
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PhilHealth Circular No. 2 s. 2001

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Surgeons
and Anesthesiologist’s fee

23. @rdahildahil_ | #ISKOMULI #Philhealth #MSHI2017
Control procedures

24. Circulars
• In 2008, Quality Assurance Committee was formed
• Consolidated functions of the Peer Review Committee and
the RVU Oversight Committee
• Composed 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
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25. Important Circulars
• Circular No. 03 s-2003 - Additional List Of
Compensable Surgical Procedures And Services In
Relative Value Scale 2001
• Circular No. 19, s-2006 - Addendum to the
Compensable Procedures in the Relative Value Scale
(RVS) 2001
• Circular No. 35, s-2006 - Case Rate Codes for claims
• Circular No. 02 s-2007 - Amendment to RVS Coding of
Laparoscopic AND Other Procedures
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Updates

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Maraming Salamat!