Pain Management APCM Documentation Checklist

Verify and record at least two chronic conditions, such as degenerative disc disease and fibromyalgia, expected to last 12 months or more.

Capture verbal or written consent for APCM services, ensuring the patient understands potential cost-sharing and their right to terminate at any time.

Record initial functional status using validated tools like the Oswestry Disability Index (ODI) or the Roland-Morris Disability Questionnaire.

Administer and document the ORT or SOAP-R score for all patients currently prescribed or considering long-term opioid therapy.

Identify barriers to care such as transportation issues for physical therapy or financial constraints regarding non-pharmacologic treatments.

Log the date and results of the Prescription Drug Monitoring Program query to ensure no duplicate prescriptions or 'doctor shopping' behaviors.

Calculate and document the total daily Morphine Milligram Equivalents (MME) to ensure adherence to CDC and state-specific dosage guidelines.

Review all current medications, including neuropathic agents and NSAIDs, to identify potential drug-drug interactions or contraindications.

Document the use of or referral to physical therapy, chiropractic care, or cognitive behavioral therapy as part of a multimodal plan.

Record the results of the most recent toxicology screen and note any discrepancies between the results and the prescribed regimen.

Use AI automation to capture and document the patient's self-reported pain score (1-10) and its impact on daily activities since the last visit.

Automate follow-up calls after epidural steroid injections or nerve blocks to document the percentage of pain relief and duration of efficacy.

AI-led screening for side effects related to pain medications, such as constipation, sedation, or respiratory issues, with immediate escalation.

Automatically track and log the duration of AI patient interactions and clinical staff review time to meet the 20-minute APCM threshold.

Utilize AI to intake refill requests, checking them against the documented care plan and the last PDMP check before routing to the physician.

Update the comprehensive care plan at least once per month to reflect changes in treatment, patient goals, or clinical status.

Document coordination with the patient's primary care physician or other specialists to ensure a unified approach to pain management.

For patients with high MME or comorbidities like COPD, document the offer or prescription of Naloxone as a safety precaution.

Ensure the patient has 24/7 access to their care plan via a secure portal, as required by APCM documentation standards.

Cross-reference documented time and tasks with specific CPT code requirements to ensure clean claim submission for APCM services.