APCM Compliance & Audit Checklist for Group Practices

Ensure each patient is linked to a single NPI for billing purposes to prevent duplicate claims across the group practice.

Maintain a centralized log of patient consent for APCM services, timestamped and stored in the EHR or AI call log.

Define logic for which physician is the 'primary' when patients see multiple providers within the same multi-specialty group.

Use AI tools to confirm eligibility and enrollment status during inbound calls to prevent non-reimbursable service time.

Implement a system to refresh patient consent annually or when a new primary provider is assigned within the group.

Deploy uniform chronic care templates across all providers to ensure consistency for audit reviewers.

Log every minute of clinical staff time, including AI-assisted phone interactions, to meet the minimum threshold for APCM codes.

Prove that patients have 24/7 access to care management, utilizing AI call routing or after-hours clinical services.

Ensure every APCM encounter includes a review of current medications, documented clearly in the shared group EHR.

Documentation must show regular checks for missing screenings or vaccinations as part of the APCM care plan.

Form a small group of lead physicians and admins to review compliance metrics and audit results monthly.

Conduct quarterly random audits of 5% of APCM claims to ensure documentation supports the billed complexity level.

Create a transparent system to attribute APCM revenue back to individual providers based on their attributed patient panels.

Maintain records of compliance training for all clinical and administrative staff handling APCM tasks.

Ensure all non-physician staff work is supervised and documented according to Medicare incident-to guidelines.