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While we are proposing that specific minutes spent furnishing APCM services for purposes of billing HCPCS codes GPCM1-GPCM3 need not be documented in the patient's medical record, we would expect that any actions or communications that fall within the APCM elements of service would be described in the medical record and, as appropriate, its relationship to the clinical problem(s) they are intended to resolve and the treatment plan, just as all clinical care is documented in the medical record

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An ACO may also request that CMS withhold their future quarterly payments until the ACO is ready for payments to resume

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