Depression & Anxiety APCM/BHI Enrollment Checklist

Confirm diagnosis of F32.x (Major Depression) or F41.1 (GAD) present for at least 12 months.

Identify patients with diabetes or heart disease who benefit most from integrated behavioral support.

Target patients on long-term SSRIs or SNRIs requiring structured medication management follow-ups.

Flag patients who have failed two or more antidepressants for intensive BHI add-on support.

Prioritize patients with recent ER visits for panic or anxiety for immediate CCM/APCM enrollment.

Record initial severity of depressive symptoms to track improvement and remission over time.

Establish an anxiety severity baseline for clinical monitoring and BHI billing documentation.

Perform and document a formal risk assessment (e.g., C-SSRS) as part of the initial enrollment.

Develop a comprehensive plan addressing both physical health and behavioral health goals with the patient.

Document current dosages, side effects, and adherence barriers for all psychotropic medications.

Set up automated AI check-ins to collect PHQ-9 scores telephonically between office visits.

Implement AI-driven phone calls to ensure medication adherence and reduce prescription gaps.

Define PHQ-9 score thresholds that trigger immediate human clinician intervention or suicide protocol.

Ensure automated call logs and screening scores flow directly into the patient's behavioral health record.

Configure AI-powered phone menus to provide immediate grounding exercises for patients in distress.

Log patient agreement for APCM and BHI services, including acknowledgement of potential cost-sharing.

Update the billing system to include G0568, G0569, and G0570 for enhanced behavioral revenue.

Use AI interaction logs to document time spent on non-face-to-face patient coordination and monitoring.

Ensure documentation satisfies BH-1 (Depression Remission) and BH-2 (Screening & Follow-up) measures.

Confirm at least one documented interaction per month to maintain APCM billing eligibility.