Pain Management Chronic Care Patient Enrollment Checklist

Confirm patient has at least two conditions like fibromyalgia and spinal stenosis expected to last 12 months.

Document that the chronic pain has persisted for at least 3 months and significantly impacts daily functional living.

Identify associated conditions such as depression, obesity, or diabetes that complicate the pain management plan.

Perform and document screenings for neuropathic pain to determine if the patient requires specialized nerve blocks.

Utilize the Opioid Risk Tool (ORT) to assess the patient's risk for opioid use disorder prior to APCM enrollment.

Catalog previous epidural steroid injections, facet blocks, or RFA procedures to establish a clinical baseline.

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

Ensure an active Pain Management Agreement is signed and uploaded to the EMR for all opioid-managed patients.

Perform and document a mandatory state PDMP check to verify the patient's current controlled substance history.

Clearly state why the patient requires monthly care coordination for medication safety and adherence tracking.

Record non-pharmacologic interventions including physical therapy, cognitive behavioral therapy, and nutrition.

Assign appropriate CPT codes like 99490 or 99439 based on the projected monthly clinical staff time required.

Use AI voice agents to call eligible patients and explain the benefits of the chronic care management program.

Deploy automated follow-up calls to capture verbal consent and answer common questions about APCM billing.

Utilize AI scheduling tools to book the initial 20-minute comprehensive care plan review with a provider.

Program AI agents to conduct monthly medication check-ins to confirm adherence and screen for side effects.

Set AI system alerts to notify staff when a monthly PDMP check is due for a specific APCM-enrolled patient.

Ensure all AI patient interactions are automatically transcribed and pushed to the EMR for audit-proof documentation.

Define measurable goals using the Oswestry Disability Index or similar scales to track progress beyond pain scores.

Document a specific plan for managing acute exacerbations of pain to reduce unnecessary ER visits.

Track referrals to physical therapy, psychiatry, or orthopedic surgery as part of the multimodal strategy.

Incorporate periodic, random UDS into the care plan schedule to ensure compliance with the pain agreement.

Document the presence or absence of opioid-induced constipation, sedation, or respiratory issues monthly.

Provide the patient with the dedicated number for after-hours care coordination and AI-assisted urgent triage.