Rheumatology Chronic Care Enrollment & APCM Checklist

Search EHR for patients with two or more chronic conditions such as RA and hypertension or lupus and CKD to meet CMS eligibility.

Prioritize patients on TNF inhibitors or JAK inhibitors who require intensive lab monitoring and REMS compliance.

Document patients who have experienced two or more flares in the past 12 months requiring steroid bursts or medication adjustments.

Confirm Medicare or commercial payer support for APCM codes 99490 or 99424 to ensure sustainable reimbursement.

Identify patients with interstitial lung disease (ILD) or cardiovascular risks associated with systemic inflammatory conditions.

Use AI-assisted call handling to explain APCM benefits and capture verbal or digital consent for monthly monitoring services.

Create digital care plans addressing physical, psychosocial, and functional goals specific to the patient's autoimmune diagnosis.

Implement AI-powered phone systems to ensure patients can report sudden joint swelling or fever after standard business hours.

Provide patients with digital resources on self-injection techniques and infection risk management while on immunosuppressants.

Designate a specific staff member or clinical team to oversee the patient's monthly progress and multidisciplinary needs.

Schedule AI-driven reminders for CBC, LFT, and creatinine labs required for patients on methotrexate or biologics.

Set up AI voice scripts to screen for 'red flag' symptoms like uveitis or severe systemic inflammation during patient check-ins.

Track and alert patients for annual infectious disease screenings necessary for continued biologic therapy safety.

Use automated workflows to gather clinical data for biologic prior authorizations and renewal windows.

Collect patient-reported outcome scores via automated digital surveys to monitor disease activity between office visits.