Workflow GuideAthenahealth

Athenahealth APCM Patient Enrollment Guide | Tile Healthcare

Optimize your Athenahealth APCM enrollment workflow. Learn how to identify eligible patients, configure athenaOne, and automate billing for G0556 codes.

Implementing Advanced Primary Care Management (APCM) within athenahealth requires a precise alignment of clinical documentation and billing configurations. This guide outlines the end-to-end workflow for enrolling patients into APCM, leveraging athenaOne’s reporting tools and AI-driven outreach to ensure compliance and maximize reimbursement for G0556-G0558 codes.

The Challenge

Many athenahealth practices struggle to identify APCM-eligible patients and manage the high volume of outreach required for enrollment, leading to missed revenue and fragmented care management documentation within the athenaOne platform.

Step-by-Step Workflow

1

Identify Eligible Patients via Report Builder

Utilize the athenahealth Report Builder to filter your patient population by chronic condition counts and insurance eligibility. Focus on patients with two or more chronic conditions who haven't had a recent wellness visit, ensuring your APCM target list is accurate before initiating outreach.

Best Practices
  • Filter by specific ICD-10 codes in Report Builder
  • Validate insurance coverage for APCM codes
Common Pitfalls
  • Including patients with only one chronic condition
2

Configure APCM Order Types in athenaOne

Update your athenaOne clinical configuration to include specific APCM order types and templates. This ensures that providers can easily document consent and the initiation of the care plan during the encounter, which is a prerequisite for billing the G0556 code family.

Best Practices
  • Create a 'Consent' order type for easy tracking
Common Pitfalls
  • Forgetting to link the care plan to the visit encounter
3

AI-Driven Outreach and Consent Capture

Deploy AI-powered call handling to contact eligible patients for APCM enrollment. The AI can explain the benefits of the program, capture verbal consent, and automatically update the patient's communication preferences or notes within the athenahealth patient chart.

Best Practices
  • Use AI to handle high-volume initial outreach
  • Sync AI call logs to athenaOne patient notes
Common Pitfalls
  • Manual outreach which slows down enrollment speed
4

Clinical Documentation in the Patient Encounter

During the patient visit, ensure the 'Care Management' section of the athenaOne chart is populated with the comprehensive care plan. Documentation must reflect the specific APCM requirements, including medication reconciliation and 24/7 access to care, to pass athena's billing rules.

Best Practices
  • Use athenaOne macros for care plan documentation
Common Pitfalls
  • Incomplete medication reconciliation lists
5

Setting up Claim Rules for APCM Codes

Configure the athenahealth billing module with custom claim rules for G0556, G0557, and G0558. This prevents claim denials by ensuring that the APCM codes are only submitted when the required documentation and time-based thresholds are met within the billing cycle.

Best Practices
  • Set up 'Hold' rules for APCM codes until month-end
Common Pitfalls
  • Billing APCM codes alongside conflicting CCM codes
6

Workflow Audit and Revenue Cycle Review

Regularly review your athenahealth 'Claim at Check-out' and 'A/R Management' reports to identify any APCM-related denials. Use these insights to refine your internal documentation workflows and ensure that the AI outreach is targeting the highest-priority patient cohorts.

Best Practices
  • Monitor the 'Unbilled Charges' worklist
Common Pitfalls
  • Ignoring claim denials for G0556 codes

Expected Outcomes

1

Increased APCM enrollment rates through AI outreach

2

Reduced administrative burden on athenaOne clinical staff

3

Improved claim accuracy for G0556/G0557/G0558 codes

4

Seamless integration of care management into athena workflows

Frequently Asked Questions

Athenahealth supports the CMS codes G0556 (Basic), G0557 (Moderate), and G0558 (Complex) for APCM. Ensure these are added to your local fee schedule and mapped to the appropriate clinical templates.

While APCM is a bundled payment, documenting time spent in athenaOne's 'Care Management' tasking area is recommended for audit protection. Use custom task types to track interactions.

Yes, Tile Healthcare integrates with your athenahealth patient list to automate enrollment calls. Our AI identifies eligible patients, explains the APCM program, and records consent directly back into the athenaOne system.

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Athenahealth APCM Patient Enrollment Guide | Tile Healthcare | Tile Health