From therapy note sample to leadership-ready risk report.
A controlled review workflow that complements the EHR. Official documentation stays in the facility system; SMEG provides risk visibility and leadership-ready findings.
Three stages. Source-backed checks. Human review before conclusions.
Notes are reviewed through an approved intake path.
- • PointClickCare export / approved intake path
- • MatrixCare export / approved intake path
- • Optima Unity / Innova / generic CSV when approved
- • PDF/text fallback only through approved secure intake
Source-aware screening with clinician-led validation.
- • CMS Pub. 100-02 Ch. 15 §220–§230
- • CMS R13437CP / CR 14252 — CY2026 KX thresholds
- • PDPM PT/OT/SLP component logic
- • MDS 3.0 Section O alignment
- • Documentation-integrity and review-trail indicators
Risk grade, patterns, and action priorities.
- • Documentation Risk Score per reviewed note
- • Plain-language issues plus source context where applicable
- • Suggested documentation improvement language for clinician review
- • Potential reimbursement/documentation-risk context when supported
- • Human review for high-priority patterns before leadership-facing conclusions
Founder-led therapy review with clear professional boundaries.
SMEG uses a COTA founder-clinician review lens for therapy documentation patterns, then presents findings as documentation-risk intelligence for facility discussion — not as legal, billing, MDS, clinical, or payer approval.
- • PT / OT / SLP documentation-risk themes
- • Skilled-need and goal-support language
- • Part A, Part B, PDPM/MDS, Section O, and supervision/cosignature indicators
- • High-priority findings for clinician-led validation
- • Compliance, legal, billing, and payer-policy decisions
- • MDS coding and official reimbursement decisions
- • Official EHR documentation and clinical decision-making
- • Final approval of any internal corrective action
The core source areas SMEG checks.
Findings are mapped to source-backed documentation-risk concepts where applicable, plus clearly labeled best-practice/documentation-integrity indicators.
Outpatient therapy services — coverage and documentation
§220 plan-of-care, §220.3 documentation requirements, §230 medical necessity. A core source area SMEG maps documentation-risk checks against.
View source ↗CY2026 KX modifier thresholds
CY2026 outpatient therapy KX threshold is $2,480, with targeted medical review threshold remaining $3,000. SMEG flags KX/threshold documentation risk for review.
View source ↗Therapy component classification
Per-diem PT, OT, and SLP component rates. SMEG checks documentation appears aligned with the stated payer/setting context.
View source ↗Section O — Special treatments & therapy minutes
MDS/PDPM-related documentation-risk checks are part of SMEG’s review logic, with payer/facility-specific review still requiring human validation.
View source ↗A sidecar review, not an EHR replacement.
Therapists keep documenting in the facility-approved EHR. SMEG provides a sidecar review report for leadership, DOR, compliance, and revenue-cycle discussion.
For the therapist
Document in the approved EHR. During a pilot, notes are reviewed through fake data first or secure approved intake only. High-risk findings come back as specific review prompts, not vague “more detail needed” feedback.
SMEG suggests what type of clinical support may be missing, where the gap appears, and why a clinician/compliance reviewer may want to address it.
For the DOR & CFO
Pilot dashboard/report: facility risk snapshot, discipline patterns, documentation themes, and examples that leadership can review.
Review trail: findings, reviewer notes, and action priorities can be tracked for internal quality improvement and documentation follow-up.
Start with a controlled pilot.
Start with fake data or a defined sample after BAA/security approval. SMEG returns a leadership-ready risk-pattern report and pilot readout call.