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 |
|---|---|---|
“Skin intact”, no inspection | A conclusion with no inspection extent or pressure points. | Document the full inspection, the pressure points, and the Braden score. (See Denial Patterns 6.1.) |
Cloned skin narratives | Identical skin language copied visit to visit. | Re-document the visit's actual inspection and any change. (6.2.) |
Risk not scored | A skin assessment with no Braden score or drivers. | Score pressure-injury risk and identify the subscale drivers. (6.3.) |
Prevention taught, no response | Prevention teaching with no return demonstration. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of a skin finding with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Erythema not classified/routed | Redness charted without a blanch response or staging route. | Distinguish blanchable from non-blanchable and route to Wounds. (6.6.) |
Skilled need not tied to dx/risk | Generic skin-monitoring claim. | Connect the assessment and prevention to the diagnosis and risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no skin/immobility evidence. | Cite the immobility and prevention needs and the taxing effort. (6.8.) |
Findings inconsistent with POC | Skin findings conflict with orders or the plan. | Align findings and the prevention plan. (6.9.) |
High risk, no prevention | An elevated Braden score with no prevention instituted. | Institute and document the prevention program. (6.10.) |