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 |
|---|---|---|
“A&O” without detail | Orientation shorthand with no memory, attention, or course. | Document memory, attention, executive function, and the course. (See Denial Patterns 6.1.) |
Cloned cognitive narratives | Identical cognitive language copied visit to visit. | Re-document the visit's actual findings and any change. (6.2.) |
Acute change not distinguished | Confusion charted without the delirium-versus-dementia distinction. | Establish the course and screen for delirium. (6.3.) |
Caregiver taught, no response | Cognitive-strategy teaching with no teach-back. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of a change with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Screen not done or not compared | A cognitive concern with no validated screen or baseline comparison. | Use a validated screen and compare to baseline. (6.6.) |
Skilled need not tied to dx/risk | Generic cognitive-monitoring claim. | Connect the assessment to the diagnosis and the specific risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no cognitive-related evidence. | Cite the supervision need or wandering risk and the taxing effort. (6.8.) |
Safety impact not addressed | Cognitive impairment charted with no safety or medication plan. | Address the safety and medication-management implications. (6.9.) |
Cognition not aligned to OASIS | Narrative cognition conflicts with the coded OASIS items. | Align the narrative with the OASIS-E2 cognitive items. (6.10.) |