Diabetes APCM Billing Code Setup Checklist

Confirm the patient has two or more chronic conditions, such as Type 2 Diabetes and Hypertension or CKD, as required for APCM.

Secure and document verbal or written consent for APCM services, explaining cost-sharing and 24/7 access to care.

Segment patients using insulin for more frequent monitoring check-ins due to higher risk of hypoglycemia.

Ensure the patient is enrolled in Medicare Part B and is not currently enrolled in a conflicting CCM or PCM program.

Screen for social determinants of health, such as food insecurity or lack of transportation, that impact diabetic diet adherence.

Record the most recent A1C level and set automated reminders for the next test based on the care plan (usually 3-6 months).

Log all changes to insulin dosages or GLP-1 receptor agonists, noting the clinical rationale for each adjustment.

Document annual screenings for diabetic retinopathy, neuropathy, and nephropathy to satisfy care coordination metrics.

Create a digital care plan accessible to the patient that includes specific glucose targets and foot care instructions.

Use a timer or automated log to record at least 20 minutes of clinical staff time spent on care coordination per month.

Set up AI workflows to call patients 7 days before their scheduled A1C lab to ensure compliance and fasting requirements.

Implement AI-driven calls for patients who recently reported low blood sugar to review symptoms and treatment protocols.

Deploy AI voice agents to handle incoming calls for test strip, sensor, and lancet refills, routing only complex issues to staff.

Schedule automated monthly check-ins to reinforce nutritional goals and record patient-reported diet adherence.

Ensure AI call transcripts and time-logs are automatically uploaded to the patient chart for APCM audit protection.