Module 3 — Audit Simulation: Resident H.M.

How this works: Read the chart packet below the way OIG, RAC, or a state surveyor would — across every section, looking for places where what's billed isn't backed by what was written. As you read, flag anything you believe is a finding using the checkboxes. When you're done, reveal your results at the bottom.

Time on this chart

00:00

1 · Face sheet / admission summary

Resident: H.M. | Age: 79 | Sex: F

Admission date: Day 1 (post 4-day acute hospital stay) | Payer: Medicare Part A

Hospital discharge diagnosis: Right-sided cerebral infarction (stroke), with new-onset left-sided weakness

SNF admitting diagnosis (Section I primary, as coded): I69.354 — Hemiplegia and hemiparesis following cerebral infarction, affecting left non-dominant side

2 · Physician admission note — Day 1

79 y.o. female s/p R MCA CVA, 4-day acute stay, now s/p transfer to SNF for rehabilitation. Pt presents with left hemiparesis, mild dysphagia per hospital SLP eval (recommends mechanical soft diet, thin liquids — re-eval in 1 week). Hospital chart notes "poor oral intake x2 days prior to discharge, ~50% of meals." Skilled PT/OT/ST services ordered for gait training, ADL retraining, and dysphagia management. Will follow.

— Dr. R. Castellano, Attending

3 · Physician progress note — Day 9

Follow-up visit. Pt tolerating therapy well, gait improving with min assist. Family reports pt "seems to be eating better." No new orders at this time. Continue current POC.

— Dr. R. Castellano, Attending

Note: no repeat SLP swallow evaluation is documented as having occurred by Day 9, despite the hospital note's 1-week re-eval recommendation falling on Day 8.

4 · Nursing note excerpts

Day 1, 1900: Pt settled into room. Family at bedside. Diet order: mechanical soft, thin liquids, per hospital recs. Pt alert, oriented x3. Skin intact.

Day 4, 1400: Pt c/o difficulty swallowing thin liquids at lunch, coughed twice during meal. Speech therapy notified. (No further SLP follow-up documented Days 4–9.)

Day 9, 0800: Pt ate approximately 75% of breakfast. No s/s aspiration noted this shift.

Day 13, 1100: Pt continues to require mod assist x1 for bed mobility and transfers. Some improvement noted in left UE strength since admission. Pt able to ambulate ~15 ft with platform walker and CGA (contact guard assist).

5 · MDS 3.0 — 5-Day assessment (ARD: Day 8) — selected items

Section GG0130 — Self-Care (admission performance, 3-day lookback)

Item	Code coded
GG0130A1 — Eating	01 — Dependent (helper does all of the effort)
GG0130C1 — Toileting hygiene	01 — Dependent

Section GG0170 — Mobility (admission performance, 3-day lookback)

Item	Code coded
GG0170C1 — Lying to sitting on side of bed	01 — Dependent
GG0170D1 — Sit to stand	01 — Dependent

Section I — Active diagnoses

• I69.354 — Hemiplegia/hemiparesis following cerebral infarction

• F32.9 — Major depressive disorder, unspecified — coded as active

Section N — Medications

• IV antibiotic (NTA-qualifying) coded as administered Days 1–3

Section K0300 — Nutritional approaches

• Mechanical altered diet: checked Yes

6 · Medication administration record — selected entries

Date	Medication	Route	Notes
Day 1	Ceftriaxone 1g	IV	Started day of admission
Day 2	Ceftriaxone 1g	IV
Day 3	Ceftriaxone 1g	IV	Last IV dose; route changed Day 4
Day 4–13	(oral equivalent)	PO

This entry is correctly reflected in MDS Section N. Confirm for yourself whether it belongs on your findings list.

7 · HIPPS code summary as billed

5-Day PPS Assessment, ARD Day 8:

• PT/OT clinical category: Major Joint Replacement / Spinal Surgery (as mapped from primary diagnosis)

• Nursing component: coded at Extensive Services level, supported in part by IV med use and depression flag

• NTA score: 4 points, including 1 point from "depression" comorbidity flag

Mark your findings

Check every box below where you believe the documentation does not support the billing or coding decision. Then click "Reveal results."

Section GG functional scoring — Eating and mobility items coded "01 – Dependent" without supporting documentation.

NTA comorbidity coding — Depression (F32.9) coded as active with no supporting clinical documentation.

Medical necessity / skilled need documentation — Swallow re-evaluation never completed despite a documented coughing episode.

Primary diagnosis / ICD-10 mapping — PT/OT clinical category doesn't match the documented neurologic primary diagnosis.

HIPPS code / case-mix classification — Multiple components of the same assessment are inflated at once.

IV antibiotic / MAR entry — I believe this is also a documentation gap.

How long did that take you — for one resident?

Most learners spend 15 to 25 minutes manually cross-referencing a single chart like this one. RevOptix1 reads every section, across every EMR, in under 90 seconds — and shows you exactly what it found, with source documentation attached.

Try the scoring tool free See RevOptix1

Audit simulation: Resident H.M.

Mark your findings

How long did that take you — for one resident?