Workflow GuideEpic EHR

Epic APCM Billing & Claims Submission Workflow Guide

Master APCM billing and claims submission within Epic EHR. Learn to automate workflows, identify eligible patients, and optimize Epic care management.

Optimizing Advanced Primary Care Management (APCM) billing within Epic EHR requires a seamless integration of care management modules and precise documentation. This guide outlines the workflow for health systems to capture billable time, synchronize MyChart interactions with phone-based outreach, and ensure claims meet CMS requirements using Epic's native tools and AI-driven automation.

The Challenge

Many health systems struggle with Epic's complex configuration for APCM, often leading to uncaptured care time, fragmented documentation between MyChart and phone calls, and high claim denial rates due to non-compliant care plan structures and manual tracking errors.

Step-by-Step Workflow

1

Identify Eligible Patients via Epic Healthy Planet

Configure the Healthy Planet registry to flag patients meeting APCM criteria based on chronic condition codes and encounter history. Use SlicerDicer to refine lists.

Best Practices
  • Use automated SlicerDicer reports for real-time lists
  • Filter by specific ICD-10 codes required for APCM
Common Pitfalls
  • Relying on manual provider referrals which misses 40% of eligible patients
2

Capture Time via Epic Care Management Module

Utilize the Care Management activity to log all minutes spent on non-face-to-face care, including AI-driven call transcripts and portal messaging interactions.

Best Practices
  • Set up SmartPhrases for standardized APCM logging
  • Enable the 'Time Capture' flowsheet for care managers
Common Pitfalls
  • Forgetting to document MyChart response time as part of billable minutes
3

Automate Outreach Documentation with AI Integration

Integrate AI call center data directly into Epic encounter notes via API to ensure telephonic outreach is automatically timestamped and attributed to the patient record.

Best Practices
  • Map AI call logs to specific Epic flowsheet rows
  • Ensure AI summaries are pushed to the 'Notes' section
Common Pitfalls
  • Manual data entry of call durations which leads to rounding errors
4

Synchronize MyChart with Phone Workflows

Coordinate patient communications by ensuring MyChart messages and AI-handled calls are visible in a single Epic timeline for the care manager to avoid redundant outreach.

Best Practices
  • Use Epic's In Basket for unified notifications
  • Flag high-priority MyChart responses for immediate AI follow-up
Common Pitfalls
  • Siloing digital and phone communications in different Epic activities
5

Validate Care Plan Documentation Compliance

Ensure the Epic Care Plan activity contains the required CMS elements, including goals, barriers, and interventions, before the billing cycle closes.

Best Practices
  • Use Epic's 'Required Fields' logic for care plans
  • Audit care plans monthly using Reporting Workbench
Common Pitfalls
  • Submitting claims without an active or updated Care Plan in Epic
6

Execute Billing via Epic Resolute PB

Route the captured time and documentation to Epic Resolute Professional Billing for automated claim generation using APCM-specific CPT codes.

Best Practices
  • Set up Charge Router rules specifically for APCM codes
  • Automate the 'Charge Trigger' based on accumulated minutes
Common Pitfalls
  • Using generic E/M codes for care management time instead of APCM-specific codes
7

Monitor Revenue via Epic Radar Dashboards

Use Radar dashboards to track APCM claim status, denial reasons, and total revenue generated per provider or clinic to ensure financial sustainability.

Best Practices
  • Customize 'Revenue Cycle' dashboards for APCM tracking
  • Set alerts for claims stuck in 'Workqueue' status
Common Pitfalls
  • Ignoring Workqueue errors for missing clinical documentation

Expected Outcomes

1

Increased APCM revenue through automated time capture and AI integration

2

Reduced administrative burden on Epic care managers and billing staff

3

Higher claim acceptance rates via CMS-compliant Epic documentation

4

Improved patient engagement through MyChart and AI call synchronization

5

Real-time visibility into APCM program performance via Epic Radar

Frequently Asked Questions

AI call handling systems use Epic's FHIR APIs or App Orchard integrations to push call logs and durations directly into the patient's record, which Epic's billing module then uses to calculate billable APCM time.

Yes, Healthy Planet is the ideal tool for building registries that identify APCM-eligible patients by filtering for specific chronic condition clusters and recent encounter data within your Epic environment.

Denials often occur when the documentation in the Epic Care Plan activity does not meet the specific complexity or time requirements mandated by CMS, or when phone outreach isn't properly linked to the encounter.

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Epic APCM Billing & Claims Submission Workflow Guide | Tile Health