APCM Implementation Checklist for Cardiology Practices

Filter for patients with NYHA Class II-IV and at least two qualifying comorbidities like CKD or Diabetes.

Flag patients requiring regular anticoagulation monitoring and rhythm status checks for APCM inclusion.

Screen recent discharge records for patients who need structured follow-up to prevent 30-day readmission.

Confirm patient insurance coverage and ensure they are not enrolled in overlapping CCM programs elsewhere.

Obtain verbal or written consent for APCM services and document it clearly within the cardiology EHR.

Use risk stratification to enroll the most unstable patients first to maximize clinical impact and revenue.

Configure AI voice agents to call heart failure patients for routine beta-blocker and ACE-inhibitor titration checks.

Establish AI-driven triggers for sudden weight gain or worsening dyspnea reported during automated check-ins.

Define AI-led outreach schedules for days 2, 7, and 14 following a cardiac-related hospital discharge.

Ensure blood pressure and weight data from remote devices flows into the APCM care coordination notes.

Develop AI scripts focused on chest pain, edema, palpitations, and medication adherence for cardiology patients.

Automate the transfer of call transcripts and summaries into the patient's record for audit-proof documentation.

Verify and record how patients can reach a clinician after hours for urgent cardiac concerns.

Ensure a comprehensive, patient-centered care plan is updated monthly and accessible to the entire care team.

Use automated timers to log at least 20 minutes of staff time per month for G0557 billing requirements.

Periodically review documentation to ensure all cardiac medications are reconciled during APCM check-ins.

Document communication between the APCM coordinator and the cardiac rehabilitation facility for post-MI patients.

Screen for social determinants of health, such as transportation barriers to follow-up cardiology appointments.