Documentation gaps
Care that was clearly delivered — but never fully captured in a way that supports the level billed.
Evidence Room for SNF audit defense
Review the chart before they ask.
PowerChart90 Evidence Room organizes an MDS/ADR packet into a source-cited evidence graph — supported, conflicting, not found in packet, or not assessable — with human disposition before any external action.
PowerChart90 login stays on this site · RevOptix1 software signs in at revoptix1.com · Expert review is a human services engagement
Sample Evidence Room · anonymized MDS packet
This week's article
PDPM Audit Checklist 2026: What Auditors Actually Look For First
Most facilities prepare for an audit by reviewing billed codes. Auditors start with certification, then work outward.
Human
review required before MDS/claim action
Source
findings cite submitted text when available
BAA
pathway before PHI — see /baa/
Homepage performance figures previously shown (facility counts, percent lift, average scan time) are marketing claims without a published study design on this site. Treat them as unverified until methodology and independent review are provided. Customer quotes below are illustrative, not controlled outcomes research.
“We caught two Section GG documentation gaps a week before our ADR deadline. That's the kind of finding that used to slip through until survey.”
Illustrative customer feedback · Director of Reimbursement
120-bed skilled nursing facility, regional chain · not a blinded validation study
The gap
The care happened. The chart didn't say so completely enough to get paid for it.
Acuity & GG scoring
Functional status and comorbidity documentation that don't keep pace with what the resident actually needed.
Audit risk
The same gaps that quietly cost revenue are the kinds of issues a MAC reviewer or state surveyor may flag.
How it works
Review. Flag. Decide. In that order — always.
Step 01
Review
We read physician notes, nursing documentation, therapy, meds, and MDS data — the chart as it already exists, nothing new to fill out.
Step 02
Flag
Findings are linked to submitted notes when a source is available — a missing packet item, a conflict, or an issue for your team to review. Dollar figures, when shown, are examples, not billed recoveries.
Step 03
Decide
Your DON or MDS coordinator reviews every finding. Nothing is auto-submitted, auto-coded, or auto-billed. Ever.
What a review produces — not a performance claim
Packet
Findings are limited to the documents you supply for that stay — not a census-wide result
Human
Disposition is required before any MDS, claim, or external action
Cited
Items are tagged supported, conflicting, not found in packet, or not assessable
About the earlier pilot sample previously shown on this page
- An internal review of 22 Medicare Part A stays in one 100-bed facility was previously displayed here with percentage and match-rate figures.
- That sample was not a random national study, not a published protocol, and not a prediction of what another facility will see.
- It did not establish underpayment, overpayment, survey outcome, or recoverable dollars.
- The $2,254 figure below: an illustrative, de-identified coded-service example from one note — not a billed recovery and not a facility-wide result.
Nothing on this page is a promise of similar results, recovered revenue, audit outcome, or survey score. It is not a substitute for current CMS RAI Manual instructions.
A closer look
One flag, start to finish.
Before review
“Wound care performed per protocol. Resident tolerated procedure well. Will continue current plan of care.”
After review
Dressing complexity, frequency, and skilled technique were present in the note but not reflected in the coded service level for the period.
→ Flagged for DON review — $2,254 illustrative unbilled example (de-identified; not a billed recovery)
Sign off on your first review
Ready to see what's in your charts?
A sample review takes one chart and about fifteen minutes. No commitment, no changes to your systems — just a clear look at what's there.