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Population Health Infrastructure

Advanced Primary Care
Management

The infrastructure layer for modern primary care practices — closing care gaps, stratifying risk, and engaging your full patient population between visits.

🟢 42 Care Gaps Closed
⚡ Risk Tier Updated
Population Health Dashboard Live
892
Enrolled
67
High Risk
94%
Engaged
Annual Wellness Visit
78%
Colorectal Screening
61%
Medication Reconciliation
89%
SDOH Screening
52%
Practice Quality Score 87 / 100

More than care management —
a primary care infrastructure

APCM extends your reach across your entire patient population, not just complex patients. It's the infrastructure layer that drives quality, closes gaps, and generates sustainable recurring revenue.

📊
Longitudinal Engagement
Ongoing touchpoints with patients between office visits — maintaining the care relationship and catching issues early.
🔍
Preventive Follow-Up
Structured follow-through on preventive screenings, wellness visits, immunizations, and routine care milestones.
🎯
Care Gap Closure
Systematic identification and closure of open care gaps — improving quality metrics and HEDIS performance.
⚠️
Risk Stratification
Continuous risk tier updates using clinical data and social drivers — ensuring high-need patients get priority attention.
📈
Quality Metric Improvement
Direct support for quality-based reimbursement programs, value-based contracts, and annual performance reviews.
🤝
Broader Coordination
Beyond any single condition — APCM supports the full patient care journey including referrals, specialists, and SDOH needs.

Everything your practice needs,
fully managed

AuriaMedical delivers every APCM workflow — from annual wellness coordination to social driver screening — without adding staff to your practice.

📅

Annual Wellness & Preventive Coordination

Outreach and scheduling support for Annual Wellness Visits, ensuring your eligible Medicare patients are seen and preventive services are completed.

🔄

Post-Visit Follow-Up

Structured outreach after office visits to reinforce care instructions, confirm medication changes, and address any patient questions before the next appointment.

🎯

Care Gap Closure Workflows

Systematic identification of open care gaps from your EHR or payer data, followed by targeted patient outreach to close each gap before it becomes a quality miss.

🩺

Screening Completion Support

Follow-up on outstanding preventive screenings — colorectal, breast, cervical, lung, diabetic eye exam, and more — supporting HEDIS and Stars performance.

🔗

Referral Loop Closure

Tracking that referred patients actually complete specialist visits, closing the referral loop and ensuring care plans are not abandoned between providers.

💊

Medication List Validation

Regular medication reconciliation outreach — confirming current medications, identifying adherence barriers, and flagging discrepancies for provider review.

🏃

Fall Risk & BMI Outreach

Proactive outreach for fall risk screening, BMI management support, and functional status follow-up — addressing preventable health events before they occur.

🏘️

SDOH Screening Support

Structured assessment and documentation of social determinants of health — food security, housing stability, transportation barriers — with resource navigation support.

Four quality dimensions
APCM directly improves

APCM is one of the highest-leverage tools for practices in value-based contracts, quality bonus programs, and MIPS reporting.

📊 Quality Data & Care Gaps

  • HEDIS measure closure tracking
  • Stars rating performance support
  • Open gap identification from payer data
  • Documentation of completed services
  • Year-round gap management, not year-end scramble

💊 Medication Management

  • Medication list reconciliation
  • Adherence barrier identification
  • High-risk medication monitoring
  • Poly-pharmacy flags for provider review
  • Post-prescription follow-up calls

🏘️ SDOH Assessment

  • Structured SDOH screening documentation
  • Food, housing, and transportation barriers
  • Community resource navigation
  • SDOH coding and billing support
  • Social risk stratification within patient population

🩺 Preventive Screenings

  • Colorectal, breast, and cervical cancer screening
  • Lung cancer screening for eligible patients
  • Diabetic eye exam and foot exam follow-up
  • Bone density screening for at-risk patients
  • Depression and cognitive screening follow-up

APCM CPT Codes &
Billing Structure

APCM uses a risk-tiered billing structure — higher complexity patients generate higher monthly reimbursement. All codes are per-patient, per-month Medicare benefit.

Low Complexity
99424
APCM — Low Complexity, First 30 Min
Patients not meeting high complexity criteria. Requires 30 minutes of clinical staff time in the calendar month, care plan, and comprehensive care management.
~$62 / pt / mo
High Complexity
99425
APCM — High Complexity, First 30 Min
Patients with serious chronic conditions or multiple complex conditions — higher time, documentation, and coordination requirements. Significantly higher reimbursement.
~$110 / pt / mo
Add-On
99426 / 99427
APCM Add-On — Each Additional 30 Min
Each additional 30-minute block of APCM clinical staff time. No monthly cap — practices with complex populations can stack significant per-patient monthly revenue.
~$55 per additional 30-min block

Build the primary care
infrastructure your panel deserves

APCM is the recurring revenue and quality engine that modern primary care practices need. AuriaMedical delivers the full program — zero lift on your staff.