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 |
|---|---|---|
“NAD” without survey | Distress shorthand with no structured general survey. | Document the survey, the baseline comparison, and the constitutional review. (See Denial Patterns 6.1.) |
Cloned general lines | Identical gestalt language copied visit to visit. | Re-document the visit's actual presentation and any change. (6.2.) |
Impression without data | A subjective “looks fine” with no findings. | Record structured survey findings and the constitutional screen. (6.3.) |
Teaching without measured response | Warning-sign teaching with no teach-back. | Document topic, method, audience, and mastery percentage. (6.4.) |
Notification without outcome | “MD notified” of a finding with no orders or response. | Close the loop: time, content, response/orders, follow-through. (6.5.) |
Cluster not recognized | Constitutional symptoms charted but the cluster not acted on. | Interpret and escalate the symptom cluster (for example sepsis). (6.6.) |
Skilled need not tied to dx/risk | Generic survey claim. | Connect the assessment to the diagnosis and the specific risk. (6.7.) |
Unsupported homebound | “Remains homebound” with no constitutional or functional evidence. | Cite weakness, fatigue, or deconditioning and the taxing effort. (6.8.) |
Findings inconsistent with POC | The gestalt conflicts with documented orders or the plan. | Align findings and the plan to the current POC. (6.9.) |
Constitutional change not trended | A decline in function or weight never compared to baseline. | Document and act on the change from baseline. (6.10.) |