Know which therapy notes need a closer look.
SMEG screens PT, OT, and SLP notes against Medicare documentation rules and builds a prioritized review list. Qualified reviewers confirm, change, or dismiss every finding, and QA releases the report.
Pt sn 30 min PT focusing on R shoulder ROM post-op rotator cuff repair. AROM: flex 95°, abd 80°. PROM tolerated to 110° flex. Tol Tx well. Will continue plan.
- REVIEW Skilled rationale is abbreviated. Review whether the note explains the therapist’s skilled decision-making and resident-specific response.
- CONTEXT Payer and service setting need confirmation. Part A coverage and PDPM/MDS context should be evaluated only when applicable to the record.
- REVIEW Functional carryover is unclear. Consider whether the record connects the measures to function and the active plan of care.
Initial OT eval. Pt presents s/p stroke with R UE weakness. AROM measured. ADL performance assessed. Plan: 5×/wk OT ×4 weeks for ADL retraining and UE strengthening.
- REC Occupational and functional context is limited. Review whether the documented weakness and ADL assessment are clearly connected to the therapy focus.
- REC Goals and baselines are not readily traceable. Review the supplied sample for clearer links between baseline function, goals, and the planned interventions.
- REVIEW Prior level and baseline detail are not visible in this excerpt. Review the complete evaluation and plan of care before concluding they are absent.
- CONTEXT Certification status is not evaluated from this excerpt. Confirm payer, plan-of-care, and certification context in the official chart.
Pt sn 30 min ST for dysphagia. Trialed nectar-thick liquids w/ chin tuck — 0/10 overt s/sx aspiration. Reinforced swallow strategies w/ pt and CNA. Continue per POC.
- CONTEXT Billing modifier cannot be evaluated from note text alone. Review the claim and payer context separately.
- REVIEW Skilled analysis is brief. Consider whether strategy selection, cueing, and clinical response are clear enough for the intended reader.
- FOUND Trial count is present. The excerpt documents 0/10 overt signs; do not flag trial counts as missing.
Fixed synthetic demonstration only. Prompts are editorial examples, not measured engine results or final clinical, billing, compliance, or payer conclusions.
Therapy documentation risk intelligence for skilled nursing facilities.
CMS reports a 17.9% improper payment rate for SNF inpatient claims in 2024, and 75.5% of it was insufficient documentation. SMEG shows therapy leaders which notes to review first.
Find patterns early
Spot repeat documentation gaps by building and discipline, then assign follow-up.
Evidence with every finding
Each finding shows the note excerpt, the rule and source behind it, and anything that could not be checked.
Priced by facility size
Scoped to your buildings. No one-size-fits-all price.
Watch the engine score a note.
Add documentation to this thin synthetic note. Every score and finding is the SMEG engine’s actual output for the note shown.
PT daily note. Medicare Part A skilled nursing facility stay.
Date of service 09/01/2026.
Resident completed therapeutic exercise and gait training per plan.
Tolerated session. Will continue per plan of care.
Measured performanceAmbulated 150 ft with rolling walker, min assist on turns. Sit-to-stand 3x10, progressed from mod assist to min assist.
Skilled rationaleTherapist adjusted walker height and cued step length after two losses of balance; fall risk requires skilled progression.
Plan-of-care goalWorking toward POC goal #2: ambulate 200 ft with supervision.
Treatment minutes97116 gait training 23 minutes; 97110 therapeutic exercise 15 minutes. Total treatment time: 38 minutes.
Signed J. Synthetic, PT, DPT 09/01/2026.
Checks this note cannot answer (4)
- Copy-paste similarity (needs the clinician’s other notes)
- Minutes add up to the total (no total time documented)
- Cloned-text pattern (needs the note batch)
- Daily skilled-service continuity (needs the full stay)
These are reported as “not evaluated,” never as passed.
Raised to High risk (the score alone is medium). Part A daily note shows no skilled rationale and no objective measurement of the patient’s response (CMS Pub. 100-02 Ch.8 §30.2.2.1).
- No reason given for why skilled therapy was needed todayraises bandshared cap−10
- Treatment minutes not documented (needed for MDS Section O)−7
- No clinical reasoning or treatment adjustment describedshared cap−5
- Skilled-need language is generic (“per plan”)shared cap−4.5
- “Tolerated session” does not describe the response−4.2
- No objective measures (distance, assist level, reps)raises band−4
- Session not linked to a plan-of-care goal−0.6
100 − 35.3 in findings + 4.5 returned by related-finding caps = 69.2
No findings. Every check that could run on this note passed.
Synthetic note; real output from SMEG rules v1.9.0 (82 rules). A score is a documentation review aid, not a coverage, payment, or audit-outcome prediction. Medicare Part B notes are scored under Part B rules, which differ.
The documentation risks SNF therapy leaders worry about.
A review layer over therapy notes. It does not replace your EHR, therapists, MDS team, or compliance officer.
Part A coverage support
Skilled need, the reason skilled care was needed that day, measured response, and goal progress.
PDPM / MDS alignment
Questions for your MDS team to review against the full record. Not a payment classification.
Therapy mode / Section O
Individual, concurrent, and group documentation, and therapy minutes.
Part B billing support
Minutes, units, KX-threshold context, and progress-report timing.
Payer-specific rules
Medicare Part A, Part B, and managed-care checks applied separately, never blended.
Leadership view
Repeat themes across buildings and disciplines, with owners and next steps.
From note sample to leadership report.
A clinician-led review workflow. Software flags; qualified people decide.
Start with a synthetic demo.
We discuss facility size, skilled beds, disciplines, and review volume. No patient records are shared.
Rules screen each note.
Checks run for the note’s benefit, setting, and note type. Qualified reviewers confirm, change, dismiss, or escalate every finding.
QA releases the report.
Recurring themes, supporting excerpts, reviewer decisions, and follow-up priorities, released only after QA review.
Learn the basics.
A plain-English guide to Medicare Part A vs Part B, PDPM, MDS, ADRs, and what makes therapy notes weak under review.
What the demo shows, and what it cannot prove.
People decide.
Qualified reviewers confirm or dismiss every finding, and QA releases the report. The official chart remains the source of truth.
Higher means fewer flagged gaps. It is a review aid, not a coverage, payment, or audit-outcome prediction. Notes without enough context are not scored.
SMEG has no completed clinical validation or customer-outcome evidence. Synthetic examples show format and workflow only.
Start with a scope conversation.
Share facility count, skilled beds, PT/OT/SLP scope, and review volume. The next step is a synthetic demonstration, not a record upload.
smeg@suprememedicalevaluationgroup.com · (818) 468-4099