APCM Audit Readiness Checklist for Geriatrics

Confirming Qualified Medicare Beneficiary status is essential for billing the higher-reimbursement G0558 code correctly during every monthly billing cycle.

Ensure all non-QMB geriatric patients meeting chronic care criteria are enrolled under the standard G0557 APCM code for consistent revenue.

Flag patients with dementia or Alzheimer's to ensure consent and care planning involve the designated legal proxy or healthcare power of attorney.

Since dual-eligibility can fluctuate, monthly verification ensures you are not under-billing for patients who qualify for the high-intensity QMB tier.

Document Social Determinants of Health, such as transportation barriers or food insecurity, which are required for comprehensive APCM care planning.

Use AI to tag and prioritize patients with a history of falls for more frequent telephonic check-ins and environmental safety assessments.

Every APCM enrollment must have a timestamped entry in the electronic health record confirming the patient or proxy agreed to the service.

For patients with documented cognitive decline, ensure the legal guardian's consent is captured and scanned into the patient's permanent record.

Store recordings of AI-driven enrollment calls to provide definitive proof of consent and patient education in the event of a Medicare audit.

Document that non-QMB patients were informed of potential coinsurance obligations to prevent billing disputes and compliance red flags.

Track quarterly changes in Medicare Advantage enrollment to ensure APCM services remain covered under the patient's specific plan rules.

The date of the face-to-face initiating visit must be clearly linked to the APCM enrollment date to satisfy Medicare look-back requirements.

Ensure all non-face-to-face time spent on care coordination is logged with specific descriptions of the actions taken for the patient.

Review all medications within 48 hours of any hospital discharge to prevent adverse drug events, a high-risk area for elderly patients.

Use automated AI outreach to check on patients after a fall and document the findings in the care plan for audit-ready clinical notes.

Integrate results from annual cognitive screenings (like MMSE or MoCA) into the APCM care plan to justify increased management intensity.

Maintain strict Transition of Care (TOC) logs for patients moving from skilled nursing facilities back to home or assisted living.

Document that medication lists are reconciled at every transition of care and at least once per quarter for stable chronic patients.

Capture every phone call or message exchange with family members, as these count toward the total care management time for APCM billing.

Keep detailed logs of communication with assisted living or independent living staff regarding the patient's status and needs.

Document annual discussions regarding Advance Directives, POLST forms, or hospice transitions as part of the holistic APCM care model.

Maintain logs of automated reminders sent to both patients and caregivers to demonstrate proactive engagement and adherence support.

Ensure notes from cardiologists, neurologists, and other specialists are reviewed and incorporated into the primary geriatric care plan.

Document referrals to community resources like Meals on Wheels or senior transport to prove the practice is addressing SDOH needs.