Nephrology Chronic Care Management Enrollment Checklist

Filter EHR records for patients with an eGFR between 15 and 59 mL/min/1.73m² to target those most in need of intensive management.

Confirm the presence of at least two chronic conditions, typically hypertension and diabetes, to meet CMS billing requirements for CCM.

Secure documented verbal or written consent, ensuring the patient understands the 24/7 access to care and potential cost-sharing.

Ensure BMP, CBC, and UACR results from the last 90 days are uploaded to the chart to establish a baseline for electrolyte monitoring.

Evaluate the patient's proximity to ESRD and document the current status of vascular access or transplant evaluation.

Automate an introductory call through an AI voice agent to explain the CCM program and verify the patient's preferred contact methods.

Set up AI reminders to verify that patients are taking correct dosages of medications like ACE inhibitors and avoiding NSAIDs.

Use AI voice assistants to collect daily weights and check for edema, escalating significant changes to the care coordinator.

Automate outbound calls to ensure patients attend critical blood draws for potassium and phosphorus monitoring.

Configure an AI call handler to answer after-hours queries regarding renal diet or medication side effects, filtering urgent issues.

Confirm Medicare or private payer eligibility for CPT codes 99490 or 99487 specifically within the renal specialty context.

Utilize software to log the required 20+ minutes of non-face-to-face care management provided by the nephrology team each month.

Designate a staff member to serve as the primary point of contact for the patient's longitudinal renal care journey.

Provide digital or physical education on low-potassium and low-phosphorus diets as part of the initial enrollment package.

Regularly review Advanced Primary Care Management notes to ensure they reflect the specific renal interventions performed.