Guidance document for processing PM-JAY packages
Sinus Excision & Curettage
Procedures covered: 1 Specialty: General Surgery
Package name Procedure name HBP 1.0 code HBP 2.0 code Package price (INR)
Excision of Sinus and Excision of Sinus and 5,000
S100050 SG034A
Curettage Curettage
ALOS: 1-2 Days
Minimum qualification of the treating doctor:
Essential: MS/ DNB/ Equivalent (General Surgery)
Special empanelment criteria/linkage to empanelment module: None
Disclaimer:
For monitoring and administering the claim management process of Excision of Sinus and Curettage, NHA
shall be following these guidelines. This document has been prepared for guidance of PROCESSING TEAM
and TRANSACTION MANAGEMENT SYSTEM of AB PM-JAY for the claims of procedures mentioned above.
The hospitals can also refer to this document so that they have the insight on how the claims will be
processed. However, this document doesn’t provide any guidance on clinical and therapeutic
management of patient. In that respect the hospitals and physicians may refer to any other relevant
material as per the extant professional norms.
PART I: Guidelines for Clinicians and Healthcare Providers
1.1 Objective:
The purpose of this section is to act as a guidance & a clinical decision support tool for the
clinicians in deciding the line of treatment, plan clinical management of patient and decide
referral of cases to the appropriate level of care (as required) for treatment of patients under
PMJAY and selection of corresponding Health Benefit Package.
It will also serve as a tool for hospitals to determine and submit the mandatory documents
required for claiming reimbursement of health benefit package under PMJAY.
1.2 Clinical key pointers:
A sinus is a blind track leading from the surface down to the tissues. There may be a cavity in the
tissue which is connected to the surface through a sinus. The sinus is lined by granulation tissue
which may be epithelialized.
Causes of persistence of a sinus
1. Presence of foreign body
2. Persistent infection
3. Distal obstruction as in enterocutaneous fistula
4. Absence of rest
National Health Authority Version 1.1 Dated August 2020
5. Epithelialization of the track
6. Malignancy
7. Nondependent drainage, inadequate drainage
8. Dense fibrosis
9. Irradiation
10. Specific causes-tuberculosis, actinomycosis.
Management
Treatment is based on etiology. However, basic principles include:
• Conservative management
• Excision
• Drainage
1.3 Mandatory documents- For healthcare providers
Following documents should be uploaded by the concerned hospital staff at the time of pre-
authorization and claims submission:
Mandatory document Excision of Sinus and Curettage
i. At the time of Pre-authorization
Clinical notes Yes
Clinical picture (private parts may be covered) Yes
Optional Yes
Sinogram / X-ray of the affected site
USG of the affected site
Planned line of treatment Yes
ii. At the time of claim submission
Detailed Indoor case papers (ICPs) Yes
Detailed Procedure / operative notes Yes
Post-operative clinical photograph (optional) Yes
Histopathological examination Yes
Detailed discharge summary Yes
PART II: GUIDELINES FOR PROCESSING TEAM
2.1 Objective: To provide guidance to the pre-authorization and claims processing team in
ascertaining the medical necessity of procedure carried out vis a vis the patient’s medical
condition as evidenced by supporting documents/investigation reports etc., in deciding the
admissibility and quantum of claim and compliance with mandatory documents by the hospital.
National Health Authority Version 1.1 Dated August 2020
2.2 Following mandatory documents to be diligently reviewed by the pre-auth / claims
processing personnel:
2.2.1 At the time of pre-authorization processing- For pre-authorization processing doctor
(PPD):
a. Clinical notes - detailed history, signs & symptoms, planned line of treatment, and
indication for procedure?
b. Were the clinical photographs submitted (optional – private parts may be covered)?
2.2.2 At the time of claim processing- For claims processing doctor (CPD)
a. Are the detailed ICPs with daily vitals and treatment details?
b. Are the detailed procedure / Operative Notes available?
c. Is the Discharge summary with follow-up advise at the time of discharge?
d. Was the histopathological examination submitted?
PART III: GUIDELINES FOR IT
3.1 Objective: To enable setting up of cross check mechanisms / rule engines within the IT
platform (TMS) to ensure compliance with STGs and to prevent fraud / abuse of the Health
Benefit Package.
3.2 Below mentioned are the scenarios where a provision would be built in TMS for pop-ups:
a. Was clinical presentation and diagnosis indicative of surgery? Yes
Till the time the functionality is being developed, the processing doctors shall check the above
manually.
References
1. K Rajgopal Shenoy, Anitha Shenoy (Nileshwar). Manipal Manual of Surgery. Fourth
Edition.
2. Somen Das. A concise textbook of surgery. Sixth Edition. 2010
National Health Authority Version 1.1 Dated August 2020
