The domain’s common reasons a Part A skilled day is down-coded or denied on medical review (ADR), and the corrected pattern. The full catalog lives in Denial Patterns.
Risk
Why it fails
Corrected pattern
Delirium not distinguished
‘Confused as usual’ without a baseline comparison.
Distinguish delirium from the dementia baseline and screen/escalate. (ADR.)
Reflexive medication
PRN psychotropic without a medical/trigger screen.
Screen for a medical trigger and document the non-pharmacologic plan (route to Behavioral).
Dementia-alone billing
Skilled billed for stable dementia care.
Tie the skilled element to a superimposed change, BPSD management, or a comorbidity.
Section C/E unsupported
Cognition/behavior coded without the note.
Carry the cognitive/behavioral data in the note. (F641.)
