Oncology APCM & Chronic Care Patient Enrollment Checklist

Identify two or more chronic conditions, such as cancer plus hypertension or diabetes, for APCM billing eligibility.

Flag patients finishing active treatment for transition into a 5-year monitoring program per NCCN guidelines.

Enroll patients on oral chemotherapy or immunotherapy requiring weekly toxicity and adherence checks.

Ensure primary cancer codes and secondary chronic condition codes are documented for CMS reimbursement.

Categorize patients by symptom severity and recurrence risk to determine AI check-in frequency.

Obtain and document patient consent for monthly APCM services and clarify potential co-pay responsibilities.

Develop a patient-centered care plan addressing physical, emotional, and nutritional needs post-diagnosis.

Document all current medications, including chemotherapy, biologics, and supportive drugs like antiemetics.

Verify that the monitoring protocol aligns with NCCN survivorship or treatment-specific follow-up standards.

Confirm caregivers and emergency contacts for rapid response during acute symptom flares or toxicities.

Configure AI call protocols for weekly monitoring of nausea, fatigue, and neuropathy symptoms.

Set up automated prompts for patients to report pain levels and breakthrough medication usage patterns.

Use AI to screen for significant weight loss or dehydration signs in gastrointestinal cancer patients.

Automate calls for upcoming infusion sessions, PET/CT scans, and specialist referrals to reduce no-shows.

Program AI to identify patients meeting criteria for open clinical trials based on new diagnostic data.

Confirm active authorizations for long-term biologics or ongoing radiation therapy cycles.

Connect patients with high out-of-pocket costs to oncology financial navigators or drug assistance programs.

Review specific requirements for private payers regarding chronic care management in oncology settings.

Integrate AI call logs with the EHR to automatically time-stamp and document billable minutes for APCM.

Screen for transportation or housing issues that may hinder treatment compliance or follow-up visits.