Workflow GuideSubstance Use Disorders

SUD Chronic Care Monthly Check-In Workflow & APCM Guide

Optimize Substance Use Disorder chronic care with this monthly check-in workflow. Ensure 42 CFR Part 2 compliance and maximize APCM BHI add-on revenue.

This workflow provides a structured framework for managing Substance Use Disorder (SUD) patients through monthly chronic care check-ins. Designed for MAT providers and addiction specialists, it integrates 42 CFR Part 2 requirements with the new 2026 BHI add-on codes (G0568-G0570) to ensure high-quality recovery support, medication adherence, and practice sustainability through automated outreach.

The Challenge

SUD practices struggle with high patient attrition and the administrative burden of 42 CFR Part 2 compliance. Manual outreach often fails to capture the structured data required for APCM billing or identify early relapse triggers in OUD and AUD patients before they lead to treatment dropout.

Step-by-Step Workflow

1

Consent & 42 CFR Part 2 Verification

Before discussing any treatment details, AI or clinical staff must verify the patient has an active, signed 42 CFR Part 2 consent form on file allowing for chronic care communication and data sharing.

Best Practices
  • Use automated triggers to flag expiring consents 30 days in advance.
  • Ensure the consent specifically mentions 'Chronic Care Management' activities.
Common Pitfalls
  • Assuming HIPAA consent covers SUD-specific 42 CFR Part 2 requirements.
  • Proceeding with clinical outreach without a verified digital signature.
2

MAT Adherence & Pharmacy Coordination

Confirm the patient has successfully filled their buprenorphine, naltrexone, or other MAT prescriptions. Identify if there are any 'prior auth' delays or pharmacy-level barriers preventing access.

Best Practices
  • Ask specifically about the last date the prescription was picked up.
  • Coordinate directly with specialty pharmacies if a gap is identified.
Common Pitfalls
  • Failing to ask about pharmacy stock issues, which are common for MAT medications.
  • Relying on EMR 'fill' data which does not guarantee patient pickup.
3

Relapse Trigger & Craving Assessment

Utilize standardized screening questions to evaluate the frequency and intensity of cravings over the last 30 days. Assess exposure to high-risk environments or social stressors.

Best Practices
  • Use a 1-10 scale for craving intensity to track longitudinal data.
  • Prompt the patient to identify one 'safe person' they contacted this month.
Common Pitfalls
  • Asking 'are you okay' instead of using structured clinical scales.
  • Ignoring subtle mentions of increased stress or sleep disturbances.
4

Co-occurring Symptom & Pain Review

Screen for changes in depression (PHQ-9) or anxiety (GAD-7) and assess chronic pain levels, as these are the primary drivers for relapse in the SUD population.

Best Practices
  • Automate the delivery of PHQ-9 via SMS prior to the monthly call.
  • Flag any score increase of 5+ points for immediate provider intervention.
Common Pitfalls
  • Treating SUD in a vacuum without addressing underlying mental health triggers.
  • Failing to document the correlation between pain spikes and craving increases.
5

Naloxone Access & Safety Planning

Verify the patient has unexpired naloxone (Narcan) on hand and that their designated emergency contact knows how to use it. Update the individualized overdose prevention plan.

Best Practices
  • Offer to send a new prescription to the pharmacy if the current supply is expired.
  • Confirm the patient knows the location of their kit.
Common Pitfalls
  • Assuming a patient in long-term recovery no longer needs a safety plan.
  • Not documenting the safety plan update in the monthly APCM note.
6

Social Determinants of Health (SDOH) Screen

Briefly check for housing instability, transportation barriers to clinic visits, or food insecurity that could jeopardize treatment adherence.

Best Practices
  • Maintain a local directory of SUD-friendly recovery housing.
  • Link patients to transportation vouchers if they miss in-person urine drug screens.
Common Pitfalls
  • Overlooking the impact of job loss on insurance coverage for MAT.
  • Assuming the patient has reliable phone access for future telehealth.
7

Billing Documentation for G0568-G0570

Ensure the total time spent across all outreach activities (calls, coordination, safety planning) meets the 20-minute threshold for APCM and BHI add-on codes.

Best Practices
  • Use AI call logging to automatically track talk time and transcription.
  • Explicitly mention 'Substance Use Disorder' as the primary chronic condition in the note.
Common Pitfalls
  • Under-reporting time spent on pharmacy coordination and family outreach.
  • Failing to use the specific 2026 SUD-enhanced BHI codes.

Expected Outcomes

1

Significant increase in 6-month and 12-month MAT retention rates.

2

Full compliance with 42 CFR Part 2 and HIPAA confidentiality standards.

3

Capture of new monthly revenue via APCM and BHI add-on codes (G0568-G0570).

4

Early identification of relapse risks, leading to lower ER and detox readmissions.

5

Improved patient satisfaction through consistent, non-judgmental digital touchpoints.

Frequently Asked Questions

The codes G0568, G0569, and G0570 allow for higher reimbursement when managing SUD as part of Advanced Primary Care Management, acknowledging the higher complexity of these patients.

Yes, provided the AI platform is HIPAA-compliant, signs a BAA, and the patient has provided specific written consent that meets 42 CFR Part 2 requirements for data disclosure.

The workflow should include an immediate 'warm handoff' or escalation trigger to a clinical provider for an emergency assessment and potential detox referral.

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SUD Chronic Care Monthly Check-In Workflow & APCM Guide | Tile Health