Workflow GuideDepression & Anxiety

Depression & Anxiety Monthly Check-In Workflow | APCM Guide

Optimize Depression & Anxiety check-ins with APCM BHI codes G0568-G0570. Automate PHQ-9/GAD-7 monitoring and improve medication adherence with AI.

This guide outlines a high-efficiency monthly check-in workflow for patients with chronic depression and anxiety. By leveraging APCM and the 2026 BHI add-on codes (G0568-G0570), practices can ensure consistent PHQ-9/GAD-7 monitoring, medication adherence, and suicide risk assessment while maximizing reimbursement through AI-driven phone automation and structured data capture.

The Challenge

Manual monthly outreach for depression and anxiety is resource-intensive, often leading to missed PHQ-9 screenings, inconsistent medication tracking, and lost revenue from BHI add-on codes G0568-G0570 due to poor documentation of clinical staff time.

Step-by-Step Workflow

1

Automated Outreach & Scheduling

AI-driven calls initiate the monthly check-in, confirming patient availability and setting the stage for the BHI-specific assessment. This reduces the administrative burden of manual dialing.

Best Practices
  • Schedule calls 3 days before the 30-day window ends
  • Use natural language AI to increase patient engagement
Common Pitfalls
  • Relying on patient-initiated calls for monthly check-ins
2

Standardized Symptom Screening

Administer the PHQ-9 and GAD-7 via AI voice or digital link to quantify symptom severity. The AI captures scores directly into the EHR for longitudinal tracking of treatment efficacy.

Best Practices
  • Compare current scores to the previous month's baseline
  • Flag any score increase of 5 points or more for provider review
Common Pitfalls
  • Collecting scores without documenting them in the APCM record
3

Medication Adherence & Side Effect Review

Verify antidepressant and anxiolytic compliance. AI identifies barriers such as cost or side effects (e.g., weight gain, insomnia) and logs them for the clinical team.

Best Practices
  • Ask specifically about the last 3 doses missed
  • Inquire about new over-the-counter supplements
Common Pitfalls
  • Assuming adherence without asking for specific pill counts
4

Safety & Suicide Risk Assessment

Execute structured protocols to identify red flags or suicidal ideation. If a patient indicates self-harm, the AI triggers an immediate, live clinical escalation to a licensed provider.

Best Practices
  • Always include PHQ-9 Question 9 in every check-in
  • Ensure a warm-transfer protocol is active 24/7
Common Pitfalls
  • Treating risk assessment as an optional component of BHI
5

Care Plan Coordination & BHI Documentation

Update the behavioral health care plan and capture all clinical data required for G0568-G0570 billing, ensuring the 20-minute threshold for APCM integration is met and logged.

Best Practices
  • Document time spent on care coordination and family calls
  • Link BHI activities to the primary chronic condition
Common Pitfalls
  • Under-reporting time spent on non-face-to-face coordination
6

Referral & Therapy Tracking

Verify if the patient has attended scheduled psychotherapy or counseling sessions. Coordinate with external behavioral health providers to ensure a closed-loop treatment plan.

Best Practices
  • Request recent session notes from community therapists
  • Update the EHR with the therapist's latest recommendations
Common Pitfalls
  • Failing to document external therapy in the primary care record

Expected Outcomes

1

Increased capture of BHI add-on revenue (G0568-G0570)

2

Improved PHQ-9 and GAD-7 documentation compliance

3

Higher medication adherence rates for antidepressants

4

Reduced provider burden through automated data collection

5

Earlier identification of treatment-resistant depression

6

Better integration of behavioral and physical health data

Frequently Asked Questions

Codes G0568-G0570 allow practices already billing APCM to capture additional revenue for the intensive monitoring required for mental health conditions like MDD and GAD.

AI can perform initial screenings using validated tools; however, any positive indicator must trigger an immediate, live clinical escalation according to safety protocols.

Under the new APCM framework, BHI add-on codes require specific documented time increments, typically starting at 20 minutes of cumulative clinical staff time per month.

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Depression & Anxiety Monthly Check-In Workflow | APCM Guide | Tile Health