PhilHealth Coverage & Discounts for Angioplasty in the Philippines
A practitioner-oriented legal briefing
1. Medical Background: What “Angioplasty” Means in Philippine Billing
| Common label on chart | Technical term in PhilHealth schedule | Typical ICD-10 / RVS codes |
|---|---|---|
| “Plain balloon angioplasty” | Percutaneous Transluminal Coronary Angioplasty (PTCA) — without stent | RVS 93510 / ICD-10 I25.10, I20.9 |
| “PCI w/ BMS” | Percutaneous Coronary Intervention with Bare-Metal Stent | RVS 92980 |
| “PCI w/ DES” | PCI with Drug-Eluting Stent (DES) | RVS 92982 / 92928 (dual stent) |
These distinctions matter because PhilHealth assigns separate “case-rate” amounts to each RVS code.
2. Statutory & Regulatory Framework
| Instrument | Key provisions for angioplasty coverage |
|---|---|
| Republic Act (RA) 7875 National Health Insurance Act as amended by RA 9241 & RA 10606 | Created PhilHealth; §28 makes “medical, surgical and other health services” reimbursable subject to a benefit schedule. |
| RA 11223 Universal Health Care Act (2019) | §5: automatic PhilHealth membership for all Filipinos; §9(d): benefit development “guided by cost-effectiveness & equity.” |
| PhilHealth Board Resolution No. 1571-2011 (start of Case-Rate policy) | Replaced fee-for-service with fixed case rates, incl. coronary angioplasty codes. |
| PhilHealth Circular 2021-0013 | Latest consolidated case-rate list (still in force 2025); angioplasty rates shown below. |
| PhilHealth Circular 2017-0021 (“No Balance Billing” rules) & §4.19, IRR of RA 11223 | Bars out-of-pocket charges to indigent, sponsored & “Konsulta” enrollees when confined in public hospitals. |
| RA 9994 (Expanded Senior Citizens Act) & RA 10754 (PWD Act) | Mandate 20 % discount + VAT exemption on “diagnostic & professional fees” after PhilHealth deductions. |
| DOH AO 2017-0003 | Requires all hospitals to furnish a billing explanation showing deductions in this order: PhilHealth → senior/PWD → HMO → cash. |
3. Current PhilHealth Case-Rate Amounts for Angioplasty (2025)
| Description (single vessel) | Case-rate ID | Total Benefit | Facility share* | Professional share* |
|---|---|---|---|---|
| PTCA without stent | 3940 | PHP 30,800 | 70 % | 30 % |
| PCI w/ bare-metal stent | 4981 | PHP 40,000 | 70 % | 30 % |
| PCI w/ drug-eluting stent | 4982 | PHP 45,000 | 70 % | 30 % |
| Each additional stent (add-on) | 4983 | PHP 15,000 | 70 % | 30 % |
* The 70/30 split is the default but hospitals may negotiate a different internal split so long as the patient is not charged beyond the total case rate for NBB-eligible members.
Important: PhilHealth does not have a “Z Benefit Package” for angioplasty. Z-Benefits are reserved for high-cost procedures where case rates would leave catastrophic gaps. CABG, not PCI, currently enjoys a Z-Benefit (PHP 550,000 gov’t hospitals / PHP 320,000 private).
4. Eligibility & Contribution Rules (as of May 2025)
| Membership category | Contribution rule relevant to claims | Notes on angioplasty cases |
|---|---|---|
| Formal economy, self-earning, OFWs | Nine (9) months premium paid within the 12-month period immediately preceding the confinement month (Circular 2024-0005) | Overseas Filipinos may elect “automatic deduction” through PRA-accredited hospitals. |
| Senior citizens (automatic under RA 10645) | No contribution test | Provide OSCA ID + filled PhilHealth Form 1. |
| Indigent & sponsored | Covered by LGU/DSWD or national subsidy; No contribution test | Protected by No Balance Billing in government facilities. |
| Lifetime / retirees | 120 total monthly contributions & at least 60 yrs old | Hospital files claim using “Lifetime ID.” |
5. Interaction with Hospital Billing
Sequence of deductions
- PhilHealth case rate (facility + PF portions).
- Senior citizen/PWD 20 % discount (if applicable).
- VAT exemption (seniors & PWDs).
- HMO coverage (if any—PhilHealth insists on “secondary payor” status for HMOs; check your policy).
- Cash or other discounts.
No Balance Billing (NBB)
- Applies only in public hospitals & only to indigent, sponsored, and senior citizens if the hospital is level 1 or 2.
- Private hospitals may charge beyond the case rate, but must give “cost-sharing menu” up front (Circular 2020-0027).
Multiple-Stent Procedures Hospital may claim one primary PCI case-rate plus the add-on rate for every additional stent (up to four under current edits system). Supply invoices for each stent must be attached to e-claims.
Outpatient or “Day-Case” PCI Permitted since 2022 for uncomplicated, single-stent cases in PCI-capable centers. Same case-rate applies; physician must indicate “24-h observation completed.”
6. Claims Process & Deadlines
| Step | Private Hospital | Government Hospital |
|---|---|---|
| Step 1: Member completes CF-1 & consent | Admitting section before procedure | Same |
| Step 2: e-Claims upload by hospital | Within 60 days from discharge | 60 days |
| Step 3: PhilHealth adjudication | 30-45 days (average); returns “RF” if docs lacking | Same; NBB cases prioritized |
| Step 4: Benefit reflected in e-Benefits eligibility portal | Facility may issue final SOA minus PhilHealth | For NBB, patient’s “zero balance” slip given |
7. Common Pitfalls & Legal Remedies
| Pitfall | Typical reason | Remedy / citation |
|---|---|---|
| Denial for “unmatched RVS–ICD10” | Physician fails to encode the coronary artery disease diagnosis in final chart | File Motion for Reconsideration within 60 days, attach amended medical abstract (PhilHealth Claims Manual v. 2023 §12). |
| Co-payment demanded despite NBB eligibility | Hospital misclassifies patient as “elective” or uses “special device” | File complaint with PhilHealth Fact-Finding (ffcr@philhealth.gov.ph); penalty up to PHP 200k & suspension (IRR §102-C). |
| Double deduction of senior/PWD discount | Billing clerk applies 20 % before deducting PhilHealth | Demand rebilling citing DOH AO 2017-0003 §VII. |
8. Coordination with Other Laws and Programs
Medical Malpractice & Informed Consent
- DOH Administrative Order 2021-004 protects patients undergoing high-risk PCI; hospitals must produce consent forms in Filipino plus local dialect where feasible.
Income Tax Deduction
- Under §34(M), NIRC, out-of-pocket medical expense in excess of PHP 100,000 for the year, incurred for a dependent, may be used as a medical expense deduction for individual taxpayers. Keep PhilHealth benefit payment notice as proof.
Employees’ Compensation (EC) Claims
- If angioplasty is work-connected (e.g., stress-induced MI for shift worker), employee may concurrently claim EC medical benefits processed by SSS/GSIS. PhilHealth remains the primary payor; EC reimburses the remainder.
9. Practical Tips for Patients & Counsel
| What to do | Why |
|---|---|
| Check your monthly contribution posting in the PhilHealth Member Portal before surgery. | To avoid “informal economy” denial if premiums are missing. |
| Secure a cost estimate (Itemized SOA) before consent; insist the hospital show the PhilHealth deduction line. | Transparency requirement under RA 11223 §44. |
| For two-vessel disease, ask cardiologist if staged PCI (two admissions) is medically acceptable; it may allow two case-rate claims rather than one add-on, lowering net cost. | Allowed by Circular 2014-0038, so long as clinically justified. |
| Senior citizens & PWDs: Bring your ID and the PhilHealth “Member Data Record” or lifetime ID. | Billing personnel often require both to apply the discount correctly. |
10. Looking Ahead
- Draft Board Resolution on Coronary Z-Benefit for Complex PCI (2025-Q3) is pending actuarial review; if approved, will increase benefit to PHP 150k for left main or multi-vessel PCI in government heart centers.
- eClaims 4.0 rollout (target December 2025) will cut adjudication time to 10 days and auto-match stent serial numbers to deter up-coding.
Conclusion
Under present rules, PhilHealth pays ₱30,800 – ₱45,000 for the first coronary angioplasty and ₱15,000 per additional stent, with No Balance Billing fully protecting indigent, sponsored, and eligible senior members in government facilities. Private hospitals may charge above these amounts, but must deduct PhilHealth first, then apply mandatory senior/PWD discounts. Mastery of the interaction among RA 11223, the case-rate circulars, and the senior citizen/PWD laws lets practitioners secure maximum coverage—and ensures hospitals avoid illegal balance billing.