CKD Chronic Care Enrollment Checklist

Ensure N18.1 through N18.5 codes are documented for accurate stage-based care management and billing.

Analyze at least two eGFR readings over 90 days to confirm chronic status versus acute kidney injury.

Confirm presence of hypertension or diabetes, which are present in over 90% of CKD cases requiring CCM.

Confirm coverage for CPT 99490 or APCM codes to ensure practice reimbursement for non-face-to-face time.

Prioritize patients with significant albuminuria (>30mg/g) for immediate enrollment to prevent rapid decline.

Obtain and document verbal or written consent, explaining the potential cost-sharing for monthly CCM services.

Enroll the patient in the AI system for automated blood pressure monitoring and symptom check-in calls.

Instruct the patient on how to use the AI-powered triage line for urgent issues like sudden edema.

Confirm the patient's preferred method for receiving lab results and medication adjustment notifications.

Trigger the first automated outreach module regarding the avoidance of NSAIDs and other nephrotoxins.

Review all current prescriptions for renal dosing accuracy based on the patient's latest eGFR.

Set specific blood pressure goals (typically <130/80 mmHg) and document them in the care plan.

Pre-program the AI system to send reminders for quarterly BMP, CBC, and urine protein assessments.

Establish baseline sodium, potassium, and phosphorus limits tailored to the patient's CKD stage.

For Stage 4 and 5 patients, document the initial discussion regarding transplant evaluation or access placement.