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 |
|---|---|---|
“Good support”, no detail | A conclusion with no support, caregiver, or social-determinant assessment. | Document the support system, caregiver capacity, and the SDOH screen. (See Denial Patterns 6.1.) |
Cloned psychosocial narratives | Identical psychosocial language copied visit to visit. | Re-document the visit's actual situation and any change. (6.2.) |
Strain noted, not addressed | Caregiver strain charted with no coordination. | Coordinate support or respite and document it. (6.3.) |
Resources taught, no response | Resource teaching with no teach-back or follow-through. | Document topic, method, audience, and mastery, and the coordination. (6.4.) |
Notification without outcome | “MD notified” of a need with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Barrier not coordinated | A social-determinant barrier identified but not addressed. | Coordinate the resource and document the plan. (6.6.) |
Skilled need not tied to dx/risk | Generic psychosocial claim. | Connect the assessment and coordination to the diagnosis and risk via M&E. (6.7.) |
Unsupported homebound | “Remains homebound” with no psychosocial evidence. | Cite the combined medical-social limitation and the taxing effort. (6.8.) |
Findings inconsistent with POC | Psychosocial findings conflict with orders or the plan. | Align findings and the plan, including coordination. (6.9.) |
SDOH not aligned to OASIS | Narrative social factors conflict with the coded OASIS items. | Align the narrative with the OASIS-E2 social-determinant items. (6.10.) |