APCM Compliance & Audit Readiness Checklist | Tile Healthcare

Ensure EHR documentation supports the diagnosis of at least two chronic conditions expected to last 12 months.

Validate active Medicare Part B enrollment prior to initial APCM outreach to avoid non-reimbursable efforts.

Document the qualifying initiating visit (AWV or E/M) within the required timeframe before APCM enrollment.

Audit for patients already enrolled in CCM, PCM, or TCM to prevent duplicate billing and compliance flags.

Confirm the patient resides in a qualifying setting (non-facility/non-hospital) as per APCM eligibility guidelines.

Maintain a timestamped record of the patient's agreement to receive APCM services and share data.

Deliver the mandatory written explanation of APCM services, cost-sharing, and the right to stop at any time.

Explicitly record that the patient was informed of potential coinsurance and deductible responsibilities.

Ensure patients are informed of the process to revoke consent and that these instructions are documented in the EHR.

Establish a workflow to re-verify patient consent and interest in continuing APCM services every 12 months.

Use CMS-vetted language in AI or human outreach scripts to ensure all regulatory points are covered during enrollment.

Maintain detailed logs of every call, text, or email sent during the enrollment phase for audit trail purposes.

Regularly audit AI-generated enrollment calls to ensure accurate information delivery and professional conduct.

Ensure all communication platforms used for enrollment are HIPAA-compliant and encrypted.

Document that the patient has designated the billing practitioner as their primary care provider for APCM.

Store all consent forms and eligibility proofs in a single, easily accessible digital repository for auditors.

Maintain records of changes to enrollment scripts and patient education materials used over time.

Periodically review a random sample of 10% of enrolled patients to ensure all documentation is present.

Precisely record the date and time consent was obtained to align with the start of the first billing cycle.

Establish a policy to keep all APCM enrollment and billing documentation for the CMS-mandated 10-year period.