17. Common audit, denial and survey risks
Patterns that draw Part A denials and survey deficiencies, with the corrected pattern and the Segment 6 cross-reference. The full catalog lives in Denial Patterns.
Risk | Why it fails | Corrected pattern |
|---|---|---|
Daily-skilled gap | Routine/aide-level days in a Part A stay. | A named skilled service each billed day, with the reason it was required that day. (Denial 6.2 + daily-skilled gap.) |
WNL without skilled assessment | Finding with no licensed-level rationale or daily basis. | Apply Mode A: finding + reason + daily/SNF-level clause. (6.1.) |
Cloned / repetitive notes | Identical daily language. | Re-document the day’s actual values and change. (Cloned note.) |
“No change” without evidence | “No change” with no assessment data. | Show what was assessed and compared, even when stable. (Baseline-with-no-value.) |
Teaching without measured response | Education “provided,” no mastery. | Topic + method + audience + mastery %. (6.3.) |
Notification without outcome / no representative | “MD notified,” no orders/response, or no representative notice. | Close the loop and notify the representative (F580). (Open-loop.) |
MDS not supported by the record | MDS codes more than the note documents. | Carry the coder’s data in the note; note and MDS agree (F641). (MDS-not-supported.) |
Restorative coded, not documented | O0500 with no program/minutes/RN eval. | Document program, minutes, carryover, and RN evaluation. (Restorative-not-documented.) |
Maintenance misframed | Plateau charted as ending coverage. | Document the skill required to maintain/slow decline (Jimmo). (Maintenance-misframed.) |
Notice not issued/documented | Coverage ends with no NOMNC/SNFABN on file. | Issue and document the NOMNC/SNFABN timely. (Notice.) |