Workflow GuideAthenahealth

Athenahealth APCM Risk Stratification & Workflow Guide

Optimize APCM risk stratification in athenaOne. Learn how to identify chronic care patients, configure billing, and automate outreach for G0556-G0558 codes.

Effective Advanced Primary Care Management (APCM) begins with precise patient identification within athenaOne. This guide outlines the technical workflow for stratifying chronic care patients, leveraging athenahealth's reporting engine and AI-driven outreach to ensure your practice maximizes reimbursement for G0556, G0557, and G0558 codes while improving patient outcomes.

The Challenge

Many athenahealth practices struggle to identify APCM-eligible patients manually, leading to missed revenue and fragmented care. Without automated stratification and outreach, clinicians spend excessive time on documentation rather than high-risk patient intervention.

Step-by-Step Workflow

1

Data Mining via athenahealth Report Builder

Access athenahealth Report Builder to create a custom report filtering for active patients with two or more qualifying chronic conditions. Ensure you include ICD-10 codes that align with CMS APCM requirements to prevent eligibility errors.

Best Practices
  • Filter by 'Active' status to avoid outreach to inactive patients
  • Include 'Last Visit Date' to prioritize patients due for an annual wellness visit
Common Pitfalls
  • Excluding patients with only one chronic condition who might still qualify for other CCM services
2

Risk Level Assignment in athenaOne

Map your identified patients to the appropriate APCM levels within athenaOne using the Risk Score or Quality Management tab. This ensures that the clinical team prioritizes patients who qualify for higher-intensity G0557 or G0558 management levels.

Best Practices
  • Use the 'Patient Risk' field to tag high-utilization patients
  • Color-code patient flags in athena to indicate APCM tier
Common Pitfalls
  • Failing to update the risk score after a new diagnosis is added to the chart
3

AI-Powered Outreach Integration

Deploy Tile Healthcare’s AI call handling to reach out to identified high-risk patients. The AI syncs with athenahealth's schedule to book intake appointments and explain the benefits of APCM, reducing the manual workload on your front desk staff.

Best Practices
  • Schedule outreach during low-volume clinic hours
  • Ensure the AI mentions the specific chronic conditions for higher engagement
Common Pitfalls
  • Using generic scripts that do not address the patient's specific chronic care needs
4

Encounter Documentation Template Setup

Build or modify athenaOne encounter templates to include specific APCM documentation prompts. These templates must track non-face-to-face time and specific care plan updates required for compliant CMS billing.

Best Practices
  • Create a 'Time Documentation' macro for quick entry
  • Link the care plan directly to the patient's problem list
Common Pitfalls
  • Forgetting to document the 'non-face-to-face' time spent on care coordination
5

Billing Rule Engine Configuration

Update the athenahealth Billing Rules Engine (BRE) to include validation checks for APCM codes G0556, G0557, and G0558. This prevents claims from being submitted without the necessary linked chronic condition diagnoses or required time thresholds.

Best Practices
  • Test the billing rule with a dummy claim before full rollout
  • Ensure the provider is listed as the 'Rendering Provider' for APCM services
Common Pitfalls
  • Submitting APCM codes without the proper primary diagnosis code attached
6

Patient Portal Engagement & Care Plan Delivery

Utilize the athenahealth Patient Portal and automated messaging to send risk-specific care plans. Ensure all communication is logged automatically in the patient chart for audit readiness and CMS compliance.

Best Practices
  • Enable 'Auto-Share' for care plan updates in the portal
  • Use athenaCommunicator to send follow-up reminders after outreach
Common Pitfalls
  • Assuming a verbal care plan is sufficient without a documented copy in the portal

Expected Outcomes

1

Significant increase in APCM enrollment rates through automated identification

2

Reduced administrative burden on clinical staff by 30% using AI outreach

3

Improved accuracy in risk-adjusted billing for G0556-G0558 codes

4

Higher patient compliance rates due to consistent portal engagement and reminders

Frequently Asked Questions

Athenahealth uses 'Time Documentation' macros within the encounter note to record non-face-to-face minutes required for APCM compliance, ensuring all care coordination is billable.

Yes, through athenahealth’s API, the AI identifies gaps in the schedule and books APCM intake appointments based on real-time availability and provider preferences.

The 'Patient List Report' or 'Report Builder' can be filtered by ICD-10 codes and the 'Number of Chronic Conditions' field to find eligible patients for APCM tiers.

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Athenahealth APCM Risk Stratification & Workflow Guide | Tile Health