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Understanding Patient Category Codes for Revenue Cycle Management

Learn about Patient Category Codes (PATCATs), their importance, structure, and common types. Discover how correct assignment impacts revenue management and collections at Navy MTFs.

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Understanding Patient Category Codes for Revenue Cycle Management

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  1. Patient Category Codes (PATCATs) Presentation to: The 2008 Navy and Marine Corps PAD/PEBLO Conference Mr. Russ Coleman 22 May 2008

  2. Objectives • Know the purpose of Patient Categories (PATCATs) • Understand why PATCATs are important • Know how PATCAT codes are structured/assigned • Be able to identify common – and not-so-common – PATCATs • Understand that PATCAT training will soon be available on-line • Understand how to use PATCAT Finder Tool • Know where to get help with PATCATs

  3. Revenue Cycle Management Is a Team Sport! PAD CLINICAL PAD UBO CLINICAL UBO RM UBO UBO PAD CLINICAL PAD CLINICAL UBO

  4. Significant Amounts of $$ Involved • FY2007 Third Party Collections Program Billings for Navy MTFs: $65.9 million • Collections in FY2007: $20.4 million (31% of billed) • Front-End Claims Denials in FY2007: $6.3 million (10% of billed) • Patient Not Covered • Supplemental Insurance • Medicare – Not Billable • HMO – No Authorization • MTF Did Not Comply With Requirements) • Estimated maximum collections possible: $48.9 million (73% of billed)

  5. Significant Amounts of $$ Involved • Correct assignment of PATCATs and identification of OHI coverage increase possible collections by decreasing Front-End Claims Denials • All funds collected by the MTF are for use at the MTF

  6. Purpose of PATCATs • PATCAT Codes are closely linked to entitlements under the Uniformed Services Health Benefits Program (USHBP) • They allow identification and grouping of patients by “types” of interest • Sponsor Service • Beneficiary Category • Special Interest Patient Groups • PATCATs are directly linked to UBO Billing • Rate to charge and method of billing

  7. Title 10, U.S. Code CHCS Registration Entitlement? Priority for Care? Agreement? Who Pays? What Rate? Inter-Agency Agreements Contracts Secretarial Designees The Making of PATCATs PATCAT

  8. Who Cares About PATCATs? • Personnel Community (DEERS) • Patient Administration • Resource Management • UBO/Medical Services Account • Management at all levels • Data Analysts

  9. What Is Affected By PATCATs? • Many CHCS functions, and downstream systems rely on PATCATs • Patient classification by Beneficiary Category • Admission & Disposition Reports • Patient Record Extracts (SADR/CAPER, SIDR, HL7) • Workload reports (MEPRS, WWR) • Bad PATCATs = Poor Data Quality = Rework, Lost Money, Bad Decisions

  10. Impact of “Bad” PATCATs • For UBO staff, bad PATCATs can cause many problems and much rework: • Not billing when you should • Billing when you should not • Billing at the wrong rate • Billing to the wrong source • Billing using the wrong forms

  11. DEERS • Information • Service • Component • Status • Special • Program CHCS Registration Function • MTF Research • Findings • ID Card • Birth Info • Orders • Contract Info • Etc, etc, etc. PATCAT (For Current Episode of Care) PATCAT Assignment – Data and Process

  12. Some Patients Change PATCAT • Active Duty Retired • Change in billing for the Sponsor • Inactive Reserve Active Duty • Change in billing for family members • Active Duty TAMP • Change in billing for Sponsor • TAMP TRICARE Reserve Select • Change in billing for Sponsor

  13. Why Patients Change PATCATs • High OPS Tempo and creation of new benefits lead to lags in updating DEERS and CHCS • Activation/Deactivation of Reserve/Guard personnel • Entry into Transition Assistance Management Program (TAMP) • Entry into TRICARE Reserve Select • Moves from Active Duty to Retiree status

  14. Why Patients Change PATCATs • Some types of care require a specific PATCAT • Occupational Health services • Workers Compensation related care • Line of Duty = “No” for Reserve/Guard

  15. Dissecting PATCATs • Basic code covers a “Category” of interest A11 = USA ACTIVE DUTY K53 = OTHER FED AGENCY/DEPT EMPLOYEE M11 = USMC ACTIVE DUTY N11 = USN ACTIVE DUTY • Sub-categories segment the group A11 A = USA ACTIVE DUTY OFFICER A11 B = USA ACTIVE DUTY ENLISTED K53 A = TREASURY DEPARTMENT K53 B = HEALTH AND HUMAN SERVICES

  16. PATCAT Codes – First Position A = Army B = National Oceanic and Atmospheric Administration C = Coast Guard F = Air Force K = “Katch-all” (many “Other” and “Special” categories) M = Marines N = Navy P = Public Health Service R = Reciprocal Agreements (U.S. with other nations)

  17. PATCAT Codes – Second Position 1x = Extended Active Duty Sponsors 2x = ROTC; Inactive Duty Guard/Reserves, TAMP/TRS, Former Members, Applicants 3x = Retirees 4x = Family Members, Former Spouses and Family Members 5x – 9x = Used to segment “K” Codes

  18. Multiple Patient Relationships • MHS Beneficiaries (Retirees, Family Members of AD or Retirees) who are also: • Civil Service Employees • Contractors • DOD Dependent School System Employees • Generally, use the PATCAT based on the MHS Beneficiary’s broadest entitlement to care

  19. Right PATCAT for Dates of Care • You may need to double-check the PATCAT data in CHCS against other data you have gathered • Be sure to use a DEERS eligibility inquiry that covers the Dates of Service – DEERS may have been updated • Be mindful that Reserve Component personnel can go from Inactive … to Active … to TAMP… and now, to TRS… all in the space of a few months

  20. PATCAT Code and Sub-Category PATCAT Code Descriptions Used in Various CHCS Reports PATCAT Table – What’s In It? 1

  21. Beneficiary Category Descriptions Used in Various CHCS Reports Form of Payment PATCAT Table – What’s In It? 2

  22. Inpatient Rate Info: Individual or Agency and Type of Rate Outpatient Rate Info: Individual or Agency and Type of Rate PATCAT Table – What’s In It? 3

  23. Categorizes patients as Sponsor or Family Member Special Interest Reporting Categories OCONUS Group Meal Sales Can you skip a DEERS check? PATCAT Table – What’s In It? 4

  24. These are the permissible values for a change of Patient Category Code during an inpatient stay. PATCAT Table – What’s In It? 5

  25. Common PATCATs *11 = Active Duty *31 = Retiree (Length of Service) *41 = Family Member of AD *43 = Family Member of Retiree *29 A = Newborn of Sponsor’s Daughter NOTE: The “*” above is for Sponsor Service (A,B,C,F,M,N,P) K92 A = Civilian Emergency K99 = Patient Not Elsewhere Classified

  26. Unusual PATCATs • Who are Supernumeraries (53 U)? • SECDEF Designees…and they include: • President and Vice President of the US • Members of the Cabinet • Article III Federal Judges • US Court of Military Appeals Judges • Secretary, Deputy Secretary, Assistant, and Undersecretaries of Defense • DoD General Counsel • Director of Operational Test & Evaluation for OSD • Secretaries, Undersecretaries, Assistant Secretaries, and General Counsels of the Military Departments

  27. Unusual PATCATs • When can we charge members of Congress and the other Supernumeraries? • Outpatient care provided in National Capital Area (NCA) MTFs • Charges waived • Outpatient care provided in MTFs outside the NCA • Members of Congress = Full Reimbursement Rate (FRR ) • All others = Interagency Rate • Inpatient Care in MTFs anywhere • Members of Congress = Full Reimbursement Rate (FRR) • All other Supernumeraries = Interagency Rate

  28. Unusual Billing Rates • Flexible Rates (FLX/FLXO) are MTF-specific rate calculations used for specialized PATCATs • Example: K76 C – GTMO • Care for local national civilians at the NH Guantanamo Bay requested by Navy/SG in Letter of 14 Jan 02 • Inpatient Day Charge = $15.00 • Outpatient Visit Charge = $45.00

  29. FY2007 PATCAT Table Updates

  30. UBO PATCAT Course On-Line Moving to a new location

  31. UBO PATCAT Course On-Line Moving to a new location

  32. UBO PATCAT Course On-Line - Registration Moving to a new location

  33. UBO PATCAT Course On-Line – Content

  34. UBO PATCAT Course On-Line – PATCAT Finder Tool

  35. PATCAT Finder Tool U.S. Military Foreign Military USPHS Coast Guard U.S. Civilians & Others Non-U.S Civilians Uniformed Services Others Secretarial Designees NOAA Use this "logic flow" tool to help identify a specific Patient Category Code (PATCAT) for a patient PATCAT Finder Tool

  36. Where To Get Help On PATCATs • MTF Colleagues – UBO staff are your friends • Understand impacts of PATCAT assignment on billing • Identify, investigate and resolve possible PATCAT errors • Points of Contact • UBO Web Site: http://www.tricare.mil/ocfo/mcfs/ubo/index.cfm • UBU Web Site: http://www.tricare.mil/ocfo/bea/ubu/index.cfm

  37. Summary - PATCATs • Purpose: PATCATs group patients to support tracking, reporting, billing • Importance: Used by many functions and systems; linked to billing for services • Structure: Service/Civilian, Category, Sub-Category • Help: Colleagues in UBO, Service POCs, UBO Web site, UBU Web site • Training: UBO Web Site • Assigning PATCATs: PATCAT Finder Tool

  38. Summary: What Kind of Errors Do We See? • Coast Guard and Public Health Service patients with Navy PATCATs • Incorrect reporting of patient care • Missed opportunities for Interagency billing • Sponsor has one PATCAT type (i.e., Retiree) while family members have a different one (i.e., Active Duty) • Incorrect reporting of patient care • Incorrect access priority given to Retiree family members who still have Active Duty family member PATCATs

  39. Summary: What Kind of Errors Do We See? • Mismatch of PATCAT and Beneficiary Category in Encounter data found in MHS Corporate Systems

  40. Summary: How Can PAD Help? • Ensure correct PATCAT assignment • Perform a DEERS eligibility check for the individual patient • Perform a DEERS Other Health Insurance (OHI) check for the patient following the eligibility check • If Sponsor Status has change update the assigned PATCAT • And update the assigned PATCATs for family members

  41. Summary: How Can PAD Help? • Hand out DD Form 2569 at least annually and collect completed/updated forms • At check-in, ask if the patient has OHI • Enter OHI information directly from the insurance card…attach copy of card to DD 2569 • Ask about whether the encounter is related to an accident • And be sure to answer the MAC question (yes/no) in AHLTA/CHCS

  42. Q&A Questions?

  43. Speaker Contact Information Russ Coleman UBO Support Team Contractor Altarum Institute Phone: (210) 832-3020 Russ.Coleman@altarum.org

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