APCM Care Plan Documentation Checklist for ACOs

Confirm the beneficiary is currently assigned to the ACO via the CMS Attribution List before initiating APCM services to ensure shared savings alignment.

Record verbal or written consent in the EHR, specifically noting the beneficiary was informed of cost-sharing and the ability to opt-out at any time.

Document at least two chronic conditions that place the patient at significant risk of functional decline or acute exacerbation, matching ICD-10 codes.

Ensure an Annual Wellness Visit (AWV) or Comprehensive Evaluation has occurred within the last 12 months to establish the care relationship.

Check internal ACO registries to ensure the patient is not concurrently billed for CCM or PCM by another provider in the network.

Formally document the designated member of the care team responsible for the patient's APCM oversight within the centralized ACO platform.

Maintain a list of all active medical problems, including physical, mental, and cognitive conditions relevant to the patient's total cost of care.

Establish specific, time-bound clinical outcomes such as blood pressure targets or HbA1c levels that align with ACO quality benchmarks.

Document a full review of all prescriptions, OTC medications, and supplements, checking for potential interactions and adherence barriers.

Record barriers to care such as transportation, housing, or food insecurity that may impact the patient's ability to follow the care plan.

Explicitly state in the care plan how the patient can access a care team member 24/7 for urgent needs to prevent unnecessary ER utilization.

Note the date the care plan was shared with the patient or caregiver and confirm their understanding of the documented goals.

Document status of cancer screenings, immunizations, and fall risk assessments to close care gaps identified in the ACO's GPRO reports.

Use ACO data to document the patient's risk level for readmission and tailor care plan interventions to mitigate high-cost acute events.

Ensure current tobacco status and counseling interventions are documented to satisfy MIPS quality measure requirements.

Document the process for contacting the patient within 48 hours of any acute discharge, integrating TCM and APCM workflows.

Record communication with specialists outside the primary care practice to ensure clinical data is captured for the ACO's total cost of care model.

Maintain a log of specific quality gaps closed during APCM interactions, such as statin therapy for patients with cardiovascular disease.

Ensure AI call systems automatically log the duration and outcome of monthly check-ins to meet the 'non-face-to-face' time requirements.

Automatically sync AI-generated call summaries and transcripts into the patient's care plan to provide a detailed audit trail of engagement.

Document instances where AI detected a clinical red flag and successfully escalated the call to a licensed ACO care coordinator.

Capture AI insights regarding patient engagement and adherence levels to prioritize high-touch interventions for at-risk beneficiaries.

Use automated tools to aggregate APCM documentation status across all participating ACO practices for executive-level oversight.

Run AI audits of documentation completeness before the end of the billing cycle to ensure all APCM claims are supported by medical necessity.