APCM Implementation Checklist for Internal Medicine

Filter your EHR for Medicare Part B and Advantage patients with 2+ chronic conditions like CHF, COPD, or Diabetes.

Prioritize patients on 5+ medications who require intensive reconciliation and monthly monitoring to prevent adverse events.

Flag patients with hospital admissions in the last 12 months for high-intensity APCM stratification to prevent readmissions.

Ensure all chronic conditions are accurately coded to maximize risk-stratified APCM reimbursement levels.

Obtain and record verbal or written consent for APCM services, explaining the cost-sharing and benefits clearly.

Screen for transportation or financial barriers that may impact adherence to the internal medicine care plan.

Configure AI to perform the required 20 minutes of monthly non-face-to-face monitoring via structured symptom checks.

Set up AI calls to verify refill status and screen for side effects among patients on high-risk cardiovascular or endocrine meds.

Establish logic where AI routes calls to a triage nurse if patients report 'red flag' symptoms like sudden weight gain or dyspnea.

Ensure AI call summaries and patient responses are automatically pushed to the patient record for seamless documentation.

Automate 24-48 hour post-hospitalization calls to reconcile medications and schedule transition of care visits.

Utilize AI voice capabilities to communicate with ESL Medicare patients in their native language for better outcomes.

Develop a structured care plan in the EHR for each APCM patient, focusing on comorbidity interactions and goals.

Use AI system logs to document every minute spent on care coordination, reaching the 20-minute monthly threshold.

Document that patients have 24/7 access to care, facilitated by an AI call assistant during after-hours periods.

Conduct monthly reviews to ensure the correct APCM codes are applied based on the patient's risk tier and time spent.

Schedule a systematic review of all active APCM care plans to update medications and specialist recommendations.

Ensure all AI-recorded interactions and patient data are stored in a fully encrypted, HIPAA-compliant environment.