Orthopedic Chronic Care Enrollment Checklist | APCM Guide

Cross-reference EHR data to find Medicare patients with comorbid conditions like osteoarthritis and spinal stenosis.

Identify patients with persistent musculoskeletal pain lasting longer than three months for APCM eligibility.

Track patients nearing the end of their 90-day global period to transition them into chronic care management.

Ensure patients with bone density issues are enrolled in a structured monitoring program for fall prevention.

Confirm the patient is not currently enrolled in a similar program with another specialist or PCP to avoid billing denials.

Define specific range-of-motion and pain-scale targets tailored to the patient's specific orthopedic diagnosis.

Review and record all prescriptions to prevent adverse drug events related to chronic NSAID or analgesic use.

Create a recurring schedule for AI-driven check-ins regarding physical therapy attendance and home exercise adherence.

Standardize the collection of pain and function data to demonstrate medical necessity for ongoing chronic care.

Distribute educational materials regarding joint preservation and lifestyle modifications for chronic conditions.

Use automated voice systems to reach out to the patient panel and explain the value of chronic care monitoring.

Properly record and store the patient's verbal agreement to participate in the chronic care program via AI interaction.

Program AI agents to ask specific questions about joint stiffness, swelling, and medication side effects monthly.

Set up automated alerts that notify the clinical team if a patient reports a significant decline in mobility or pain.

Utilize AI to log the duration of every patient interaction to ensure compliance with Medicare billing minutes.