Workflow GuideDepression & Anxiety

APCM Enrollment Guide: Depression & Anxiety Management

Streamline APCM enrollment for depression and anxiety patients. Learn how to use BHI add-on codes G0568-G0570 and AI automation for better outcomes.

Enrolling patients with depression and anxiety into Advanced Primary Care Management (APCM) requires a structured approach to capture Behavioral Health Integration (BHI) revenue. By leveraging new 2026 codes G0568-G0570, practices can provide the intensive follow-up required for medication management and PHQ-9/GAD-7 monitoring while ensuring financial sustainability through AI-driven call workf...

The Challenge

Practices often struggle to identify eligible patients, perform required suicide risk assessments, and maintain the consistent monthly contact necessary for BHI add-on billing, leading to missed revenue and poor clinical outcomes for high-risk behavioral health populations.

Step-by-Step Workflow

1

Population Identification & AI Outreach

Utilize EHR data to flag patients with MDD or GAD diagnoses and those with elevated PHQ-9/GAD-7 scores. Deploy AI-powered call systems to automate the initial outreach, explaining the benefits of the APCM program and scheduling the enrollment visit.

Best Practices
  • Target patients with co-occurring chronic conditions like diabetes for maximum impact
  • Use AI to handle high-volume initial screening calls
Common Pitfalls
  • Failing to filter for patients already receiving incompatible specialty psychiatric services
2

Consent and Clinical Assessment

Conduct the face-to-face or telehealth enrollment visit. Obtain formal consent for APCM and BHI services, and perform a baseline suicide risk assessment. This step is critical for establishing the medical necessity of the G0568-G0570 add-on codes.

Best Practices
  • Document verbal consent clearly in the EHR to meet CMS requirements
  • Explain the cost-sharing responsibilities to the patient upfront
Common Pitfalls
  • Skipping the suicide risk assessment during the initial enrollment encounter
3

Collaborative Care Plan Development

Create a patient-centered care plan that includes psychotherapy coordination, antidepressant medication management schedules, and specific score reduction targets for PHQ-9 and GAD-7 assessments.

Best Practices
  • Include the patient's personal goals for functional improvement
  • Ensure the plan is accessible to all members of the care team
Common Pitfalls
  • Creating generic care plans that don't address specific anxiety triggers
4

Automated Monthly Symptom Monitoring

Implement AI-driven phone workflows to collect PHQ-9 and GAD-7 scores monthly. The AI can conduct these standardized screenings via voice, automatically populating the EHR and flagging patients with worsening scores for immediate clinical intervention.

Best Practices
  • Schedule AI calls at times when patients are most likely to answer
  • Use natural language processing to detect subtle shifts in patient sentiment
Common Pitfalls
  • Relying on patients to manually return paper forms via mail
5

Medication Adherence & Side Effect Tracking

Use automated outreach to monitor compliance with SSRIs, SNRIs, or other prescribed medications. AI can identify barriers to adherence, such as cost or side effects, and escalate these issues to the pharmacist or provider.

Best Practices
  • Sync outreach with prescription refill dates
  • Provide automated education on the delayed onset of antidepressant benefits
Common Pitfalls
  • Waiting until the next office visit to address medication non-adherence
6

BHI Documentation and Billing Audit

Consolidate all AI-captured data and clinical coordination time into a monthly report. Ensure that the 20+ minutes of care management required for APCM and the specific BHI add-on requirements are met before submitting claims for G0568-G0570.

Best Practices
  • Use structured templates to capture non-face-to-face time
  • Audit documentation monthly to ensure compliance with mental health parity laws
Common Pitfalls
  • Under-reporting time spent on psychotherapy coordination and specialist follow-up

Expected Outcomes

1

Increased capture of G0568-G0570 BHI add-on revenue

2

Improved PHQ-9 and GAD-7 score tracking across the patient population

3

Reduced clinical burnout through AI-automated patient follow-up

4

Enhanced medication adherence and reduction in treatment-resistant episodes

5

Consistent documentation for MIPS behavioral health quality measures

Frequently Asked Questions

The new codes are G0568, G0569, and G0570, designed to provide additional reimbursement for the intensive management of behavioral health conditions within an APCM framework.

AI call systems use natural language processing to detect high-risk keywords. If a risk is identified, the system immediately triggers an emergency protocol, bridging the patient to a live clinician or crisis line.

Yes, as long as the primary care practice is coordinating the care and managing the medical aspects of the depression or anxiety, the APCM and BHI codes can be billed.

While APCM is often bundled, the BHI add-ons typically require a minimum of 20 minutes of clinical staff time per month dedicated specifically to behavioral health coordination.

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APCM Enrollment Guide: Depression & Anxiety Management | Tile Health