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 |
|---|---|---|
Score without context | Intensity number with no location, quality, goal, or function. | Pair the score with location, quality, goal, and functional impact. (See Denial Patterns 6.1.) |
Cloned pain narratives | Identical pain language copied visit to visit. | Re-document the visit's actual findings and any change. (6.2.) |
“Controlled” without evidence | “Pain controlled” with no scale or function. | Show the score, the goal, and the functional status. (6.3.) |
Teaching without measured response | Analgesic or safety teaching with no return-demo or teach-back. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of pain with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Intervention without reassessment | Analgesic given with no post-intervention score. | Record the reassessment score and the functional effect. (6.6.) |
No adverse-effect screen on opioids | Opioid regimen with no sedation, respiratory, or bowel assessment. | Screen and document sedation, respiratory status, and bowel function. (6.7.) |
Unsupported homebound | “Remains homebound” with no pain-related evidence. | Cite pain-limited ambulation or transfers and the taxing effort. (6.8.) |
Wrong or no scale for nonverbal | Self-report assumed for a nonverbal patient. | Use a validated observational scale (for example PAINAD). (6.9.) |
Pain present, regimen not evaluated | Documented pain with no evaluation of the analgesic regimen. | Evaluate regimen adherence, effect, and adverse effects. (6.10.) |