MCC Chronic Care Enrollment & APCM Checklist

Filter patient database to identify individuals with three or more active chronic conditions to meet G0557/G0558 criteria.

Confirm patient has active Medicare Part B and is not currently enrolled in a conflicting care management program.

Review the last 12 months of hospital encounters to prioritize patients at the highest risk for readmission.

Screen for social determinants of health, such as transportation or financial instability, that impact MCC management.

Use AI call logs to identify patients who frequently call with complex symptoms or medication confusion.

Gather medication records from all outside specialists to create a single, unified master list.

Identify and resolve drug-drug interactions caused by treatments for different chronic conditions.

Explicitly state the complexity of managing multiple conditions and the need for frequent care coordination.

Set up the AI call handling system to provide patients with immediate access to care instructions at any hour.

Create measurable goals for each of the patient's primary conditions within the centralized care plan.

Secure and document patient consent for APCM services, explaining the monthly cost-sharing if applicable.

Educate the patient on how the AI-powered phone system prioritizes their complex needs for faster clinical response.

Set the first comprehensive review meeting to align the patient on their multi-condition management strategy.

Provide condition-specific guides that address the interplay between their various chronic illnesses.

Trigger an automated call or text to confirm enrollment and provide the dedicated MCC care line number.

Identify every specialist treating the patient and establish a communication cadence for care updates.

Set up automated alerts to notify the care team immediately upon a patient's discharge from any facility.

Document how the practice manages treatment plans that may conflict across different chronic conditions.

Use AI to call patients after specialist visits to capture new orders or medication changes immediately.

Initiate and document discussions regarding the patient's long-term care preferences and directives.