LITERAL EVIDENCE / DETERMINISTIC RULE CONTEXT / HUMAN CONTROL

MDS / PDPM coding review.
Show the support.

ChartTrace connects SNF source documentation, literal evidence and deterministic rule context so qualified reviewers can inspect a proposed MDS/PDPM result before approving it.

EVIDENCE BEFORE APPROVAL

Beyond finding a mismatch.
Understand the reason.

If you are evaluating MDS audit software or an MDS scrubber, a flagged item is only the beginning. Your team still needs to find the supporting documentation, understand the applicable instruction and decide what to do next.

ChartTrace’s approach to MDS accuracy review keeps those pieces together. AI assists with extracting relevant statements. Deterministic checks evaluate defined inputs. A human reviews the evidence, resolves gaps and owns the decision.

CHARTTRACE / REVIEW EXAMPLESYNTHETIC · NO PATIENT DATA
01 / SOURCE DOCUMENTATION

Oral-hygiene observation

The activity was completed at the sink.

02Staff provided verbal cues only; no physical assistance was needed.

One excerpt. Assessment timing and usual performance are not established here.

02 / LITERAL EVIDENCE“Verbal cues only”

The supporting words stay linked to line 02.

03 / RULE CONTEXTSection GG · oral hygiene

Compare the observation with the applicable assistance definitions and assessment instructions.

04 / PROPOSED RESULTA candidate for review

The excerpt suggests supervision. It cannot establish the final assessment response by itself.

05 / HUMAN DECISIONMore context required

Confirm the assessment window, usual performance and any conflicting documentation before approving a result.

An observation can be supported while the final coding decision remains open. Inspect the interactive workflow

AI-ASSISTED MDS CODING

Automation with
a review boundary.

Automated MDS review is useful when the team can inspect its basis. An AI-generated statement is not a substitute for the source record.

  1. 01

    Find the supporting statement

    Keep the exact source language and location visible alongside the coding question.

  2. 02

    Inspect the rule and exceptions

    See the applicable context, missing support and conflicts instead of treating a candidate as a completed assessment.

  3. 03

    Keep the final call with a reviewer

    Approve, reject or return a recommendation for clarification. Retain the reasoning behind that action.

A focused role in
your SNF workflow.

ChartTrace supports evidence-backed coding and billing review. It is not presented as a complete EHR, billing platform, clearinghouse, collections service or outsourced RCM team.

Confirm supported MDS items, PDPM rules, source inputs and deployment requirements during evaluation. Rule coverage and available capabilities are established for the agreed scope.

PUT THE REVIEW IN CONTEXT

Bring a review question.
Trace the answer.

Discuss your MDS/PDPM review process, current documentation challenges and the capabilities your team needs.

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EVIDENCE. RULES. HUMAN CONTROL.

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