Workflow GuideNextGen Healthcare

NextGen Chronic Care Risk Stratification & APCM Workflow

Optimize APCM patient identification and risk stratification within NextGen Healthcare to maximize chronic care management revenue and outcomes.

This guide outlines the end-to-end process for identifying and stratifying chronic care patients within NextGen Healthcare. By leveraging NextGen’s Population Health tools and integrating AI-driven call handling, practices can automate the outreach and enrollment process for APCM-eligible patients, ensuring higher compliance and recurring revenue without increasing administrative burden.

The Challenge

Many NextGen practices struggle to identify APCM-eligible patients across disparate modules like NextGen PM and EHR, leading to missed revenue opportunities and inefficient manual outreach that overwhelms front-desk staff and delays care coordination.

Step-by-Step Workflow

1

Configure NextGen Population Health Filters

Define clinical criteria within the NextGen Population Health module to isolate patients with multiple chronic conditions. Focus on those with high-utilization histories or recent ED visits to prioritize APCM eligibility based on ICD-10 codes.

Best Practices
  • Use the 'Condition' filter to group ICD-10 codes for common chronic diseases
  • Validate filter results against NextGen PM encounter history to ensure active status
Common Pitfalls
  • Relying solely on manual chart audits which are prone to human error
  • Ignoring patients with inactive statuses in NextGen PM
2

Run NextGen Risk Scoring Algorithms

Execute the Risk Score calculation within the EHR to assign quantitative values to patient profiles. This allows for data-driven stratification into high, medium, and low-risk tiers rather than subjective clinical judgment.

Best Practices
  • Refresh risk scores monthly to capture new diagnoses and changes in health status
  • Customize the risk algorithm to weight specific comorbidities relevant to your specialty
Common Pitfalls
  • Using outdated HCC data for risk calculations
  • Failing to update the risk algorithm when CMS guidelines change
3

Trigger AI-Powered Patient Outreach

Sync the risk-stratified list with an AI call handling system. The AI contacts patients to explain the APCM program benefits, answers common questions, and captures initial verbal interest to reduce manual phone volume for staff.

Best Practices
  • Ensure AI scripts mention the practice name exactly as it appears in the NextGen portal
  • Set up bi-directional data flow for automated call outcome logging into patient charts
Common Pitfalls
  • Sending automated calls without a clear opt-out path
  • Failing to sync the outreach list with the NextGen 'Do Not Call' registry
4

Document APCM Enrollment in NextGen EHR

Use the specialized 'Care Management' template in NextGen EHR to document the patient's verbal or written consent. This is a critical regulatory step for meeting CMS audit requirements for APCM billing.

Best Practices
  • Create a 'Quick Pick' or macro for APCM consent documentation to save time
  • Link the consent note directly to the master care plan within the EHR
Common Pitfalls
  • Failing to document the specific date and time of consent
  • Storing consent forms in external folders instead of the NextGen document manager
5

Configure APCM Billing in NextGen PM

Set up the charge entry rules in NextGen PM to automatically flag APCM codes such as G0511 or 99490 with necessary modifiers based on the patient's primary insurance and practice location.

Best Practices
  • Test billing rules in the NextGen sandbox environment before going live
  • Verify that the rendering provider is correctly linked to the APCM encounter
Common Pitfalls
  • Hard-coding modifiers that vary by payer
  • Neglecting to update the NextGen Master Files with the latest APCM codes
6

Monitor Care Minutes via NextGen Dashboard

Utilize the NextGen Report Writer or HQM dashboard to track the 20-minute threshold for APCM billing. Ensure all non-face-to-face time is captured accurately within the care management module.

Best Practices
  • Set up weekly email alerts for patients nearing the 20-minute billing threshold
  • Audit time logs for overlap with other billable services like Transitional Care Management
Common Pitfalls
  • Billing before the minimum 20-minute time requirement is met
  • Failing to reconcile time logs with the final claim in NextGen PM

Expected Outcomes

1

Increased APCM enrollment rates through automated AI outreach

2

Higher per-patient monthly revenue with accurate NextGen PM billing configuration

3

Reduced manual staff workload by automating the risk stratification and call process

4

Improved MIPS quality scores through better chronic disease management tracking

5

Audit-ready documentation stored directly within NextGen EHR templates

Frequently Asked Questions

NextGen Population Health uses clinical data from the EHR and claims data from the PM to filter patients based on ICD-10 codes, age, and encounter frequency, allowing for automated identification of those with two or more chronic conditions.

Yes, AI systems can be integrated via API or SFTP exports to initiate outreach calls. The AI can explain the program, capture verbal consent, and then push that status back into NextGen EHR as a task or encounter note for clinical review.

The primary codes include 99490 for standard chronic care management and G0511 for FQHC/RHC settings. These must be configured in the NextGen PM Master Files with appropriate modifiers to ensure clean claim submission.

Practices should use the NextGen Care Management module to log time. Custom reporting through SQL or the NextGen Report Writer can then aggregate these minutes to ensure the threshold is met before a claim is generated in the PM system.

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NextGen Chronic Care Risk Stratification & APCM Workflow | Tile Health