Cardiology APCM Compliance & Audit Readiness Checklist

Verify patient has 2+ chronic conditions expected to last 12 months, such as Heart Failure (I50.x) and Atrial Fibrillation (I48.x).

Ensure verbal or written consent for APCM is recorded in the EHR, including acknowledgment of cost-sharing responsibilities.

Audit patient records to ensure they are not concurrently enrolled in CCM, PCM, or TCM services with another provider.

Document the initiating visit where the comprehensive cardiovascular care plan was established or significantly updated.

Verify the patient meets the higher-level complexity requirements if billing G0558 for advanced heart failure management.

Maintain documentation proving patients have 24/7 access to the care team for urgent cardiac symptoms or concerns.

Use AI call center logs to document monthly non-face-to-face interactions, including duration and clinical topics discussed.

Record all adjustments to Guideline-Directed Medical Therapy (GDMT), specifically for ACE inhibitors and Beta-blockers.

Ensure structured follow-up calls occur within 7 days of cardiac-related hospitalizations to prevent readmissions.

Document INR monitoring or DOAC adherence checks for patients with AFib or prosthetic heart valves.

Document the patient's New York Heart Association functional classification in the care plan at least quarterly.

Ensure the comprehensive care plan is available electronically to all providers within the cardiac care team 24/7.

Document referrals to and progress within cardiac rehabilitation programs for post-MI or post-surgery patients.

Record screenings for hypertension, hyperlipidemia, and diabetes management as part of the holistic care plan.

Use AI outreach to identify and document social determinants of health that impact medication adherence.

Confirm that no other specialty (e.g., Primary Care) is billing APCM or CCM for the same patient in the same month.

Ensure the highest level of specificity for cardiology codes to support the medical necessity of APCM.

Maintain secure, HIPAA-compliant archives of AI-driven patient interactions as supporting evidence for time spent.

Audit the use of Modifier 25 when APCM services are initiated during a significant, separately identifiable E/M visit.

Conduct a random review of 10% of APCM claims against EHR documentation to ensure all 13 service elements are met.