Cardiology Chronic Care Enrollment Checklist | Tile Healthcare

Use specific ICD-10 codes for heart failure (I50.x) to build a master list of potential APCM candidates for clinical review.

Flag patients requiring regular monitoring for warfarin or DOACs to ensure adherence and prevent stroke complications.

Identify patients with 2+ chronic conditions, such as CHF and Diabetes, which qualify for higher-tier complex CCM billing.

Target patients discharged within the last 30 days for intensive follow-up to meet CMS readmission reduction goals.

Confirm that patient payers recognize the new APCM codes to ensure reimbursement for the care management team.

Identify patients with persistent high blood pressure needing titration and frequent remote monitoring contact.

Ensure the patient understands the benefits of 24/7 access and how the program helps manage their specific heart condition.

Inform patients how they can reach the cardiology care team after hours for urgent cardiac symptoms.

Clearly explain any copays associated with CCM or APCM to the patient to avoid future billing disputes.

Create a patient-centered care plan in the EHR that addresses cardiac goals, medications, and rehab needs.

Identify the staff member or AI-powered service responsible for the monthly 20-minute patient interaction.

Verify that the enrollment process covers all 13 CMS-required elements, including medication reconciliation.

Define specific systolic and diastolic goals for hypertension patients within the care management software.

Set protocols for AI outreach to trigger alerts if a heart failure patient gains more than 3lbs in 24 hours.

Establish a cadence for checking adherence to blood thinners and monitoring for any signs of internal bleeding.

Ensure care managers review rehab attendance and exercise tolerance during monthly check-in calls.

Create workflows for adjusting GDMT (Guideline-Directed Medical Therapy) based on remote monitoring data.

Coordinate care management calls with ICD or pacemaker alerts to address potential arrhythmias promptly.

Use AI voice agents to conduct the required monthly check-ins, capturing vital signs and symptom changes for the team.

Program AI to call heart failure patients 48 hours after discharge to confirm medication pick-up and follow-up apps.

Configure AI to recognize keywords like 'shortness of breath' or 'swelling' and escalate to a nurse immediately.

Ensure all AI-driven patient interactions are automatically timestamped and uploaded for APCM billing audit trails.

Reduce no-show rates for critical diagnostic tests by using AI to confirm appointments and prep instructions.

Implement automated surveys to track side effects and adherence for patients on high-intensity statin therapy.