Heart Failure APCM Enrollment Checklist | CHF Care Management

Distinguish between reduced and preserved ejection fraction to apply specific Guideline-Directed Medical Therapy (GDMT) protocols.

Verify the presence of two or more chronic conditions expected to last at least 12 months, maximizing G0557/G0558 reimbursement.

Record the New York Heart Association Functional Classification (I-IV) in the EHR to justify care intensity.

Confirm an echocardiogram has been performed within the last 12 months to document current LVEF percentages.

Heart failure patients average 4-6 comorbidities; document all to support the high-complexity APCM billing tier.

Secure and document verbal or written consent for APCM services, explaining cost-sharing and 24/7 access benefits.

Enroll the patient in the AI-powered call system to automate the collection of daily weights and edema checks.

Set personalized fluid intake limits (e.g., 1.5L or 2L) and input these into the AI monitoring system for patient reminders.

Record the patient's target dry weight in the system to trigger alerts when weight gain exceeds 2-3 lbs overnight.

For patients with cognitive decline, register a caregiver to receive automated alerts and monitoring summaries.

Review use of ACEi/ARB/ARNI, Beta-blockers, MRAs, and SGLT2 inhibitors as per latest ACC/AHA guidelines.

Define the 'sliding scale' for diuretic adjustments based on AI-reported weight fluctuations to prevent ER visits.

Ensure any patient hospitalized for CHF is seen or called within 48 hours to prevent 30-day readmissions.

Assess eligibility for cardiac rehabilitation to improve functional capacity and long-term outcomes.

For NYHA Class IV patients, initiate conversations regarding advanced care planning and palliative support.