April 2019

Thought Leader Q&A — Tuesday’s Child: A Chat With Chuck Buck
By Lee DeOrio
For The Record
Vol. 31 No. 4 P. 8

Some people call Tuesdays the worst day of the week. The reasoning goes something along the lines that on Mondays at least you can regale your coworkers with stories from the weekend, somewhat softening the blow of the start of another work week.

But don’t tell Chuck Buck that Tuesdays are the new Mondays. Buck, the publisher of ICD10monitor, is also the executive producer and program host of Talk Ten Tuesdays, a web-based broadcast that tackles the most pressing issues in the HIM sphere. The broadcasts average 700 listeners, with archived versions receiving between 25,000 and 30,000 “plays” in a 30-day period.

In his typical jovial style, Buck engages industry experts on a wide range of topics, ranging from clinical documentation improvement (CDI) to tricky coding conundrums and sticky reimbursement issues.

Buck took time out from his busy schedule and a recently completed move into new digs to answer a series of questions on the state of the industry, in particular auditing concerns. He admits to leaning on the expertise of J. Paul Spencer, CPC, COC, a senior health care consultant for DoctorsManagement, who has been reporting on the Medicaid recovery audit contractors (RACs) for RACmonitor and Monitor Mondays for more than five years.

For The Record (FTR): When did Talk Ten Tuesdays first hit the airwaves?
CB: Talk Ten Tuesdays went live in May 2013. The broadcast was an adaption of the Monitor Mondays live internet broadcast that I created to report on the RACs back in 2010. Monitor Mondays has been on the air—live—since then, every Monday except for federal holidays. I had a radio/TV background before I entered the health care business. It seemed to make sense to have a news-oriented live radio broadcast. So, Talk Ten Tuesdays was a natural outgrowth. This coming Tuesday [March 19] will mark our 361st edition, not counting the live remote broadcasts we’ve done in the past from conventions.

FTR: What topics generate the most interest?
CB: Coding and CDI topics are favorite topics. Erica Remer, MD, my cohost who is a former ED doc, is very popular. Listeners love her straight talk. One of the highlights has been when we have had the [Office of Inspector General’s (OIG)] Dan Levinson on our live broadcasts. He is so very personable and approachable. Imagine health care’s top cop being so accessible. (He’s quick to say, “Call me Dan.”)

FTR: Any particular moments stand out over the years?
CB: One time, during one of our live remote broadcasts—I think during [a Health Care Compliance Association] convention—one of the OIG’s enforcement officers was on the broadcast. During a break, I asked if she [was] “packing.” She pulled up her pant leg to reveal a holstered gun.

FTR: After so many broadcasts, do you still have the same enthusiasm?
CB: I must tell you what a thrill it is to go live every Tuesday morning. I’m on the West Coast and to check in with the panelist during our “green room” chat and to hear them talk about the weather, issues, etc, is amazing. And then we go live—just to think of all those people who are hearing us live is really breathtaking. I am so grateful for the opportunity. My dad was an NBC radio producer in Hollywood during the golden days of live radio. I think of him every Monday and Tuesday morning, remembering how I would watch him when he threw the cue to the NBC announcer to open the show.

FTR: On to the “serious” stuff. What do you consider to be the most significant differences between Medicare and Medicaid RACs?
CB: The biggest differences are the scope and the focus. Originally, the Medicaid RAC program was operating in many more states than it is today. By statute, Medicaid RACs can only audit claims sent through traditional Medicaid programs. Medicaid Managed Care plans are exempt from RAC activities, and this sharply limits the number of claims that can be audited. As for the focus, it would make sense that based on the different types of services covered by Medicaid on the state level, as opposed to those from the Medicare program, Medicaid RAC audits tend to focus more on professional services, rather than those provided by facilities.

FTR: Which of those differences presents the greatest operational challenge to the providers and why?
CB: The Medicare RAC program, simply based on its size, and the current fractured appeals process, wins the operational challenge trophy running away. The Medicare RAC program has broken the Medicare Appeals Process, with no satisfactory solution in sight.

FTR: Both the Medicaid RACs and managed care insurers are anecdotally reported to be issuing more clinical validation denials in which provider documentation is clear and the coder has reported the correct code but the auditor questions the validity of the provider’s diagnosis. The auditor’s clinical qualifications are rarely identified. Some auditors seem to be applying Milliman or InterQual admission criteria to significant secondary diagnoses in order to excuse removing them. For example, if the condition was serious, and/or the care wasn’t extensive, the code is removed regardless of meeting federal coding guidelines. To your knowledge, how significant a challenge is this on a national scale?
CB: Given the quality of the RAC work product up to the present time, I have no reason to trust clinical determinations of any RAC. Unless you have a physician conducting such audits, which is completely unlikely, any findings brought forth by a typical RAC auditor challenging clinical information should be appealed as a matter of course.

FTR: RAC denials, especially those from Medicaid, can comprise automated denials in small monetary amounts or major admission denials and everything in between. What are your thoughts regarding when—and whether—to appeal?
CB: Anecdotal evidence strongly suggests that the Medicaid RAC appeals process is much more contentious in its early stages. I am always in favor of appeal if all involved on the provider side (physician, coder, compliance officer, denial management team) agree that the denial should be challenged. Automated denials are much harder to appeal, as for both Medicare and Medicaid RAC, these are a function of data harvesting rather than a human determination.

FTR: More and more software hits the market every year, advertised to make coders’ and CDI reviewers’ lives faster and easier and their work more accurate. Without naming names, what kind of product seems to really deliver the best on its promises (eg, CDI automated pre-review, computer-assisted coding, automated E&M calculators, other)?
CB: I am always reluctant to promote one software package over another, as a software package is only going to be effective if its programming and functions reflect present-day policy. I shall say that CDI professionals always need to be involved in the process.

FTR: Of the available types of software assistance packages for coders/CDI use, again without naming names, what risks should users be aware of?
CB: I would revert to my previous answer. A software package is as good as the timing of its updates.

FTR: What would be your advice to coders entering the field today?
CB: Curiosity is key. When you make the determination that coding will be the focus of your career, dare to branch out and continue expanding your base knowledge. In the new paradigm, cross-training into facility coding from professional coding—and vice versa—will benefit not only you but also the organizations that employ you going forward.

FTR: Can you recommend any best practice industry standards for internal coding education and accuracy audits?
CB: In this question, I see a middle and an end, but not a beginning. Solid, reputable data analytics must be utilized not only as a foundation for determining your practice’s/facility’s level of risk but also as a building block to a successful audit plan. At the conclusion of internal accuracy audits, finding a secondary source to verify the results can provide an extra level of certainty regarding the audits’ conclusions. Effective coding education depends on the audience. If the education is with a provider, understanding going in that you are not a physician and the physician is not a coder goes a long way in building a rapport for effective education.

— Lee DeOrio is editor of For The Record.