Diabetes APCM Implementation Checklist | Tile Healthcare

Query EHR for ICD-10 codes E11.x and E10.x to build the initial candidate list.

Focus enrollment efforts on patients with uncontrolled glucose who benefit most from coordination.

Check for hypertension, CKD, or obesity to maximize the value of the APCM care bundle.

Record verbal or written consent in the EHR as required by CMS for billing eligibility.

Use automated AI voice agents to explain APCM benefits and schedule initial care plan visits.

Ensure all diabetic complications are accurately coded to reflect the true complexity of the patient.

Configure AI to call patients every 3-6 months based on their last laboratory results.

Automate weekly calls to insulin-dependent patients to screen for low blood sugar events.

Use automated scheduling to ensure 100% compliance with neuropathy screening requirements.

Track and follow up on retinopathy screenings with external ophthalmology partners via AI.

Deploy AI surveys to track compliance with GLP-1, SGLT2, and metformin regimens.

Provide patients with an AI-powered line to report high readings and receive immediate guidance.

Ensure all time spent on care coordination, including AI-managed interactions, is documented.

Log discussions regarding medical nutrition therapy and physical activity goals.

Revise the EHR care plan at least annually or after any significant change in health status.

Identify barriers like food insecurity or lack of transportation that impact diabetes management.

Ensure continuous glucose monitor data is reviewed and summarized in the monthly APCM log.

Verify that all automated phone interactions are encrypted and meet privacy standards.