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 |
|---|---|---|
“Communicates well”, no detail | A conclusion with no speech, sensory, or literacy assessment. | Document speech, language, functional hearing/vision, and comprehension. (See Denial Patterns 6.1.) |
Cloned communication narratives | Identical communication language copied visit to visit. | Re-document the visit's actual findings and any change. (6.2.) |
Barrier noted, not accommodated | A barrier charted with no accommodation. | Arrange and document the accommodation and confirm comprehension. (6.3.) |
Teaching without confirmed comprehension | Teaching with a yes/no confirmation rather than teach-back. | Confirm understanding by teach-back and document the result. (6.4.) |
Notification without outcome | “MD notified” of a barrier with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Family used as interpreter for clinical info | A family member used to interpret medical information or consent. | Use a qualified medical interpreter and document it. (6.6.) |
Skilled need not tied to dx/risk | Generic communication claim. | Connect the assessment and accommodation to the diagnosis and risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no communication-related evidence. | Cite the communication and associated limitation and the taxing effort. (6.8.) |
Consent without confirmed understanding | Consent obtained without verified comprehension through an accommodation. | Confirm comprehension with the accommodation before consent. (6.9.) |
Comprehension not aligned to plan | Teaching documented without evidence the patient understood it. | Document demonstrated comprehension tied to the plan. (6.10.) |