17. Common audit and denial risks
System-specific patterns that draw denials and additional documentation requests, with the corrected pattern and the Segment 6 cross-reference. The full catalog lives in Denial Patterns.
Risk | Why it fails | Corrected pattern |
|---|---|---|
Mood stated, no screen | A mood impression with no validated screen. | Administer and document a validated screen (PHQ, GAD-7). (See Denial Patterns 6.1.) |
Cloned psychiatric narratives | Identical mental-health language copied visit to visit. | Re-document the visit's actual findings, scores, and any change. (6.2.) |
Risk not screened or documented | No documented risk screen or, when positive, no response. | Screen for risk and document the level and the safety response. (6.3.) |
Teaching without response | Treatment or coping teaching with no teach-back. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of a finding with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Medical cause not considered | A behavioral change attributed to psychiatry without excluding a medical or delirium cause. | Distinguish a primary psychiatric presentation from a medical cause. (6.6.) |
Skilled need not tied to dx/risk | Generic mental-health-monitoring claim. | Connect the assessment and response to the diagnosis and risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no psychiatric-related evidence. | Cite the symptom severity restricting leaving home and the taxing effort. (6.8.) |
Findings inconsistent with POC | Mental-health findings conflict with orders or the plan. | Align findings and the plan, including referrals. (6.9.) |
Mood not aligned to OASIS | Narrative mood conflicts with the coded OASIS mood items. | Align the narrative with the OASIS-E2 mood items. (6.10.) |