Oncology APCM Billing Code Setup Checklist

Screen for patients with cancer plus one other chronic condition like diabetes or hypertension that impacts treatment efficacy.

Identify patients in remission who require 12+ months of monitoring for late-onset treatment effects or recurrence surveillance.

Confirm payer-specific requirements for APCM codes (G0511 or similar) specifically for oncology-led care coordination.

Obtain and document verbal or written consent for APCM services, explaining the role of AI-assisted monitoring calls.

Ensure time spent coordinating with trial sponsors is flagged as eligible care management time for APCM billing.

Set up automated AI calls to collect Patient Reported Outcomes (PROs) including pain scores, fatigue, and nausea levels.

Program AI to immediately route calls to a triage nurse if a patient reports a fever over 100.4°F or severe neutropenic symptoms.

Use AI to verify oral chemotherapy adherence and supportive care medication usage (anti-emetics) between infusion visits.

Ensure all automated patient interactions are timestamped and pushed to the EMR to prove the 20-minute monthly threshold.

Align AI-gathered symptom data with Common Terminology Criteria for Adverse Events (CTCAE) for clinical billing accuracy.

Create digital care plans addressing nutrition, palliative needs, and psychosocial support accessible to the entire care team.

Review monthly logs to ensure at least 20 minutes of staff/AI time is documented for each enrolled APCM patient.

If in the Enhancing Oncology Model, ensure APCM billing does not duplicate payments for the same care management services.

Confirm that the AI call system provides patients a direct path to an oncology clinician for urgent after-hours concerns.

Ensure AI check-ins include questions about food security and transportation, which are required components of APCM.