LITERAL EVIDENCE / DETERMINISTIC RULE CONTEXT / HUMAN CONTROL
An original review aid for SNF MDS, coding and RCM teams: eight prompts for testing whether the documentation supports the result.
Identify the assessment type, reference date, review purpose and applicable guidance version before comparing results.
Keep the assessment and rule versions with the review. If two systems disagree, confirm they are evaluating the same inputs and period.
For each questioned response, identify the specific source, location and observation that supports it. Distinguish direct documentation from a later summary.
If support is absent, record the question and responsible reviewer in your secure workflow. A blank evidence field is not an affirmative finding.
Compare the proposed response with the source language and relevant related assessment items. Look for a changed response whose underlying evidence has not changed.
Investigate differences before accepting a correction. Preserve the original result and the reason for the reviewer’s decision.
Identify the documented diagnosis and assess whether the applicable MDS item’s documentation, timing and active-diagnosis instructions are met.
A historical problem-list entry alone may not answer the current assessment question. Escalate unclear status to the qualified reviewer; do not infer a diagnosis.
Identify the activity, type and amount of assistance, applicable assessment period and evidence of usual performance. Read the complete context around an isolated sentence.
Clarify vague assistance language or conflicting observations. Do not treat a single observed episode as the final assessment response without the required review.
Review the supported assessment inputs behind the classification question. Confirm the applicable mapping and classification version when comparing outputs.
For a HIPPS mismatch, work backward to the assessment and contributing inputs. A matching code does not by itself establish documentation sufficiency.
Separate missing evidence, conflicting evidence and an apparent rule mismatch. Each requires a different next action.
Record what is unresolved, who will clarify it and what would close the question. Do not overwrite a conflict with a convenient interpretation.
Confirm that the reviewer has inspected the source, rule context and unresolved items before approving or returning the proposed result.
Keep the decision, rationale and reviewer identity in the appropriate secure record. Completing this public checklist does not approve an assessment or release a claim.
This is a focused documentation and coding-review aid, not an exhaustive MDS audit, clinical assessment, compliance certification or payer-specific checklist.
The excerpt below gives a reviewer something concrete to inspect. It also exposes what is missing: the wider assessment context. That distinction is central to ChartTrace MDS/PDPM coding review.
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.
The supporting words stay linked to line 02.
Compare the observation with the applicable assistance definitions and assessment instructions.
The excerpt suggests supervision. It cannot establish the final assessment response by itself.
Confirm the assessment window, usual performance and any conflicting documentation before approving a result.
The prompts above are ChartTrace’s original review framework. They do not reproduce a CMS or third-party checklist.
Consult the RAI Manual for assessment instructions, including Section GG and diagnosis guidance, and CMS PDPM resources for the applicable classification materials. Confirm the version effective for the period under review.
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