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 |
|---|---|---|
ADL status without levels | “Independent” or “needs help” with no graded assistance levels. | Grade each ADL and IADL by the level of assistance. (See Denial Patterns 6.1.) |
Cloned functional narratives | Identical functional language copied visit to visit. | Re-document the visit's actual performance and any change. (6.2.) |
Decline not captured | A functional change never compared to baseline. | Document the change from baseline and the tasks affected. (6.3.) |
Transfer/device taught, no response | Transfer or device teaching with no return demonstration. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of a decline with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Referral without follow-through | A therapy need identified but not coordinated. | Document the referral, the coordination, and the plan. (6.6.) |
Skilled need not tied to dx/risk | Generic functional-monitoring claim. | Connect the assessment and coordination to the diagnosis and risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no functional evidence. | Cite the assistance and device needs and the taxing effort. (6.8.) |
Findings inconsistent with POC | Functional findings conflict with orders or the plan. | Align findings and the plan, including therapy orders. (6.9.) |
Function not aligned to OASIS | Narrative function conflicts with the coded OASIS items. | Align the narrative with the OASIS-E2 self-care and mobility items. (6.10.) |