A chart review for the facility team, before a MAC review

The checklist PDF is a working list for the facility team. It is not a buyer’s memo, and it is not legal, coding, or billing advice. Your clinicians and reimbursement staff still decide what to change.

Start where a reviewer starts: certification

A reviewer of a skilled nursing claim does not begin with the billed code. They begin with the physician certification and recertification that support the stay. If certification is missing, late, or does not support the level of care billed, the MDS, the HIPPS calculation, and the claim are exposed even when the rest of the notes look complete.

Facility question: Do certifications on the stays you pulled support the level of care billed, or is the language generic enough that it would not hold up under review?

Look for a repeating ADR or TPE pattern

One documentation gap is ordinary. The same gap on many stays is what tends to draw an additional documentation request or a Targeted Probe and Educate review. CMS describes that medical-review path on the SNF 5-claim probe and educate review page.

Facility question: Across the stays you opened, does one gap type — a diagnosis, a therapy-minute threshold, a HIPPS driver — repeat often enough to be a pattern?

Name the denial theory before you write the response

Exposure usually follows one of two theories: a coverage question under a Local or National Coverage Determination, or a medical-necessity question about whether the clinical picture supported the level of care billed. They take different chart work. Coverage gaps and necessity gaps are not fixed the same way.

Facility question: For the highest-acuity PDPM categories in this building, does the clinical narrative support medical necessity on its own, separate from the MDS coding?

Reconcile the note, the MDS lock, and the claim for the same stay

For a representative set of stays, put three things on one page: the supporting clinical note, the locked MDS, and the claim that was billed. A contradiction between the narrative and the billed codes, or missing support for the PDPM drivers behind the HIPPS, is the item the team fixes, explains, or watches. PDPM classification uses resident characteristics in the chart and on the MDS. CMS publishes the payment rules on the skilled nursing facility PPS page, and MDS item coding, including Section GG, is in the RAI User’s Manual.

Facility question: Would the billed HIPPS make sense to someone who had only read the clinical notes? If not, name the stay, the source note, and the chart action.

Use headlines as context, not as the chart

Labor, occupancy, and PDPM policy headlines describe the environment. They do not describe this building’s record. A facility in a favorable market can still have a repeating documentation gap, and a facility under pressure can still have a defensible chart. Sector news never substitutes for the stay in front of you.

Four tests a finding has to pass

Before a gap goes on the facility action list, it has to clear four tests:

1. Is it in the chart? Does the clinical record support the coded acuity, separate from what was billed?
2. Can the team still act? Is there a practical chart action — correct the assessment, add the missing support, or explain why the record already supports the item — while the window is open?
3. Would the record hold up? Would this documentation survive an ADR, a TPE cycle, or a MAC review as it is written today?
4. Does it change this stay? Does the gap change the MDS, the claim, or the survey story, or is it a one-off note that does not?

What the facility does next

The output is a chart action, assigned to a person on the team:

• Fix now — the chart and the MDS disagree, and a qualified person can correct the assessment or add the supporting note before a reviewer opens the record.
• Keep watching — the same gap shows up on more than one stay, so the team tracks it while more charts are reviewed.
• Ask the expert team — the pattern is large enough that the facility wants a person from PDPM Audit Optimization Group on the file. That retainer is separate from the software pilot. Talk to an expert.

The record the reviewer will open

A census report says what the building billed. It does not say what the chart would show under review. Start at certification, test for a repeating ADR or TPE pattern, reconcile the note, the locked MDS, and the claim, and run each finding through the four tests before the review date arrives.

RevOptix1 compares the chart with the MDS for that work. A patent application has been filed. This page does not describe its claims. Continue with PDPM audit software, MDS audit software, software prices by bed count, and security and the BAA. Watch the demo on sample data, or talk to an expert at (385) 888-7447.