CMS’s new Advanced Primary Care Management (APCM) program represents a significant opportunity for practices to enhance patient care while improving reimbursement. Our RevCare platform already delivers all required APCM components – from enhanced communication and care transitions to alternate care delivery methods – capabilities many competitors have yet to develop. With over 700 successful implementations serving 250,000+ patients across 370+ conditions, MD Revolution delivers these advanced care components today and stands ready to guide your practice through this important transition.
MD Revolution brings deep expertise in CMS program implementation, having helped practices nationwide succeed with chronic care management, remote patient monitoring, principal care management and other programs. Our comprehensive understanding of CMS requirements, combined with our proven RevCare platform technology, positions us uniquely to support your APCM implementation.
We offer practices a complete suite of services to ensure APCM success:
From initial implementation to providing ongoing clinical care services to support APCM and your practice, MD Revolution serves as your ongoing partner in APCM success. We continuously monitor regulatory changes, update best practices, and provide optimization recommendations to ensure your practice maximizes both patient outcomes and financial returns.
Let MD Revolution help determine if APCM is right for your practice and create a customized implementation plan. Contact our team today to schedule a personalized consultation and learn how we can support your transition to advanced primary care management.
Advanced Primary Care Management (APCM) is an innovative program established by the Centers for Medicare & Medicaid Services (CMS) for 2025. APCM is being launched to address longstanding challenges in primary care delivery, including fragmented care, inadequate compensation for comprehensive services, and the need to better support practices in managing complex patient populations and social determinants of health.
At the core of APCM is the transformation of primary care practices into data-informed care teams. These teams use evidence-based protocols, patient registries, and electronic health record capabilities to:
At MD Revolution, we’re excited about how APCM may transform primary care delivery in ways that align closely with our mission to enhance care coordination, improve patient outcomes, and reduce administrative burden for healthcare providers.
Advanced Primary Care Management aims to strengthen primary care by recognizing and supporting comprehensive, longitudinal care management. Unlike traditional fee-for-service models, APCM bundles various care management services into a single monthly payment. This approach allows practices to focus on delivering high-quality, patient-centered care without the burden of tracking multiple billing codes.
Key objectives of APCM include:
The APCM model payments are designed to offer practices a stable, predictable revenue stream that supports required infrastructure and appropriate compensation for enhanced services. These prospective payments can be used to support a range of care management and coordination activities, providing participants with greater financial flexibility to develop and expand capabilities to meet patients’ care needs.
APCM services can be provided by clinical staff under the general supervision of the billing practitioner, qualifying as a “designated care management service” under § 410.26(b)(5). Unlike current care management services, APCM code descriptors are not time-based. This change recognizes that ongoing care management and coordination are standard parts of advanced primary care, even in months when documented clinical staff time doesn’t reach traditional billing thresholds or when patients don’t meet existing clinical conditions for care management services.
Additionally, APCM removes timeframe restrictions found in current communication technology-based services codes. The new G0556, G0557, and G0558 codes eliminate restrictions related to E/M services (such as the 7-day look-back and 24-hour look-forward rules for virtual check-ins), providing greater flexibility in service delivery.
CMS has established three new HCPCS G-codes for APCM services, each tailored to different levels of patient complexity, but providing some prospective reimbursement for all Medicare beneficiaries:
These tiered payments recognize that patients with multiple chronic conditions or social risk factors require more intensive care management.
APCM includes 13 core service elements that build upon existing Chronic Care Management (CCM) and Principal Care Management (PCM) services, recognizing that care management is a key component of advanced primary care delivery. While APCM shares many elements with these programs, it eliminates time-tracking requirements to allow practices to focus on comprehensive care delivery. APCM emphasizes having the necessary capabilities to provide advanced primary care while allowing flexibility to tailor services to individual patient needs.
To bill for APCM services, practices must demonstrate capabilities in all these areas. However, CMS proposes flexibility in how these services are delivered, recognizing that care needs and the services provided will vary month to month.
MD Revolution’s remote care management platform is well-positioned to support APCM implementation, aligning closely with the program’s key elements. Our solutions enable 24/7 care access, comprehensive care management, and population health analytics. Our patient engagement tools facilitate enhanced communication, while our analytics capabilities support performance measurement and quality improvement. This alignment allows practices to seamlessly transition to the APCM model, leveraging our existing remote care management infrastructure to meet new program requirements and improve patient outcomes.
APCM services can be billed by physicians and qualified healthcare professionals who serve as the focal point for all needed health care services and are responsible for a patient’s primary care. This includes:
Medicare beneficiaries are eligible for APCM services. The level of service (G0556, G0557, or G0558) depends on the patient’s number of chronic conditions and Qualified Medicare Beneficiary status.
Attribution Process
Patient attribution in APCM is intended to be based on patient choice and documented consent. Specifically:
MD Revolution’s care management platform includes robust features for documenting and managing patient consent and attribution, allowing for easy tracking of patient assignments to specific providers, ensuring compliance with APCM’s single-provider billing requirement. Additionally, our platform’s annual review capabilities align well with the expected yearly attribution update process.
While exact dates may be subject to change, the current proposed timeline for APCM implementation is as follows:
To participate in APCM, practices must have certain technological capabilities:
As the industry moves towards APCM implementation, practices and health systems will need to assess their current capabilities and identify areas for improvement. Technology solutions can play a crucial role in helping practices meet APCM requirements and deliver high-quality, comprehensive primary care under this new model.
MD Revolution’s comprehensive platform has been designed and stands ready to meet these technology requirements.
APCM builds upon existing quality and reporting pathways, which should provide efficiencies in compliance. CMS seeks to create a low burden way for practitioners to furnish APCM services by appropriately recognizing ways in which they may meet APCM billing requirements as part of existing programs and initiatives, including other ways that practitioners may be fulfilling these performance measurement requirements.
A practitioner who is part of a TIN that is participating as a Shared Savings Program ACO or a REACH ACO, or a Primary Care First or Making Care Primary practice would meet these requirements by virtue of the Shared Savings Program and CMS Innovation Center quality reporting, assessment of quality performance, accountability for total cost of care, and other program and model requirements.
For MIPS-eligible clinicians, CMS proposes linking APCM payment to quality reporting through the Value in Primary Care Merit-based Incentive Payment System (MIPS) Value Pathway (MVP). This MVP is especially well-suited to reflect the delivery of care using the advanced primary care model as it was developed to include quality metrics that reflect clinical actions that should be considered the foundations of primary care.
For practitioners who are not MIPS-eligible but participate in an Advanced APM and achieve Qualifying APM Participant (QP) status, CMS proposes the requirements are met for APCM performance measurement.
Clinicians ineligible for MIPS for other reasons, such as practitioners who are newly enrolled in Medicare or bill a low volume of Medicare services, technically could bill for APCM services. However, newly enrolled practitioners are only excluded from MIPS for one year, after which the practitioner would either be a MIPS eligible clinician who would need to report the MVP in order to bill for APCM services, or excluded from MIPS on another basis such as QP status. In the case of practitioners with low Medicare volume, CMS anticipates that they would be unlikely to bill for APCM services since the delivery of advanced primary care generally involves time and resources to establish practice-level infrastructure, and the economies of scale usually make this a more likely investment if the infrastructure can be utilized across a larger patient panel.
It’s important to note that the final rules for APCM quality measurement and reporting are not yet determined. The information provided is based on the current proposal and may change in the final rule.
Practices should assess their current quality measurement capabilities and consider how they align with the final APCM requirements. Platforms like RevCare that support comprehensive quality reporting and improvement will be invaluable for practices transitioning to the APCM model. MD Revolution’s approach is to provide services to allow practices to meet these requirements and will include data access, analysis and actionable care based on stratification or care gaps.
MD Revolution’s comprehensive platform and expertise can help practices navigate these challenges and maximize the benefits of APCM.
The introduction of APCM signals a significant shift in how CMS values and reimburses primary care services. Key implications include:
As the healthcare industry prepares for APCM, practices utilizing advanced care management platforms like MD Revolution’s will be well-equipped to adapt to these changes and thrive in this new primary care landscape.
CMS has designed APCM to build on lessons learned from several CMS Innovation Center models that were designed to improve payment for and encourage long-term investment in primary care and care management services. For example, practitioners participating in the ACO REACH model, the Making Care Primary model, and the Primary Care First model would automatically satisfy several of the APCM requirements through their model participation, including:
These models use attribution methods that review the most recent two years of Medicare claims to identify whether a model participant is responsible for a Medicare beneficiary’s primary care, which aligns with the initiating visit requirements for APCM services. The models also include risk stratification and quality and cost performance metrics that align with the Value in Primary Care MVP.
Around-the-clock access and continuity of care, patient population-level management, and performance measurement are considered essential capabilities for delivering advanced primary care. CMS is evaluating whether practitioners in other CMS Innovation Center models may also satisfy some of the APCM service elements and requirements.
The Advanced Primary Care Management (APCM) program represents an evolution of existing care management programs, incorporating elements from several current initiatives while introducing new concepts. Here’s how APCM compares to and builds upon existing programs, including information on concurrent billing and program replacements:
While APCM replaces some existing care management programs, it allows for concurrent billing of certain specialized services. This approach provides comprehensive primary care while still recognizing the need for specific, intensive services in certain cases.
Practices transitioning to APCM will need to carefully review their current billing practices and adjust their workflows to ensure they are maximizing appropriate reimbursement while avoiding duplicate billing. MD Revolution’s platform and expert team is designed to help practices navigate these changes, ensuring compliance with billing rules while optimizing revenue under the new APCM model.
For the most up-to-date and authoritative information on APCM, refer to these official CMS resources:
CMS Proposed Rule for CY 2025 (see pages 249-314 for APCM details)
Several healthcare organizations, legal experts and think tanks have published analyses of the APCM proposal:
APCM stands for Advanced Primary Care Management, a Medicare-funded initiative that supports primary care providers (PCPs) in delivering ongoing, patient-centered care. This proactive approach goes beyond occasional check-ins, aiming to keep patients engaged with their healthcare providers, ensure adherence to treatment plans, and address health issues early on.
Q&A from Understanding APCM: Requirements, Technology & Implementation webinar.
This Q&A resource compiles the key questions and answers from the webinar, Understanding APCM: Requirements, Technology & Implementation. It covers essential topics like compliance, technology integration, and practical steps for implementing Advanced Primary Care Management. Designed to address your most pressing questions, this guide serves as a practical tool for navigating the APCM model and optimizing care delivery.
In case you missed it, the webinar is available on-demand here.
A: Medicare beneficiaries are eligible for APCM services. The level of service (G0556, G0557, or G0558) depends on:
• Level 1 (G0556): Patients with one or fewer chronic conditions
• Level 2 (G0557 Patients with two or more chronic conditions
• Level 3 (G0558): Qualified Medicare Beneficiary patients with two or more chronic conditions
A: These codes are not affected by telehealth codes or visits. They will be billed the same as current CCM and RPM codes with the location being in the office.
A: Yes, absolutely. APCM services can be provided alongside ACO participation and RPM services. Like how CCM works with RPM, these programs complement each other, particularly in driving patient accountability and satisfaction.
A: MD Revolution will be ready to support APCM services starting January 1, 2025. We recommend practices begin preparation now by:
1. Completing our APCM readiness assessment
2. Evaluating patient populations for APCM eligibility
3. Planning workflow adjustments
For practices not ready to implement APCM in January, you can also start with traditional CCM and transition when ready. To facilitate future transitions, our consent process covers both CCM and APCM programs for all new enrollments.
A: Not that we are aware of. CCM and RPM services can currently be provided if someone is being seen at a SNF so all guidance points to this program being billed the same way.
Providers will need thorough documentation including verbal patient consent,
eligibility verification (confirmation of chronic conditions and primary care attribution), and service detail (care coordination efforts, patient communication, and interventions).
Payment for APCM codes will not be performance-based but tied to providing required care management services. Over time, performance measurement (e.g., quality outcomes, patient engagement) may influence payment adjustments.
Our data analytics approach leverages multiple data sources, including your existing EHR system (including Epic), practice analytics platforms, claims data when available, and real-time patient monitoring data. Using these sources, we perform comprehensive patient data analysis to stratify patients into APCM tiers, identify care gaps and needs, and assign appropriate interventions and goals. For practices without existing analytics capabilities, we offer access to ReportingMD’s population health platform through our partnership to ensure robust data analysis capabilities.
Yes, APCM follows a single-provider attribution model similar to other Medicare care management programs. Only one provider (identified by their NPI number) can bill APCM services per patient per month, and this requires documented patient consent.
There are major changes in billing structure for FQHCs and RHCs next year as well, detailed in this article. Starting in 2025, FQHCs will transition from the general G0511 to specific service-based codes for programs such as CCM, PCM, PCM, RTM, APCM and others. FQHCs will have the same billing rules are non-FQHCs, but will have a 6-month grace period to make adjustments to their workflows, billing systems, staff training, etc.
If you are interested in learning more about what this means for FQHCs specifically, be sure to complete a readiness assessment form and we will schedule some 1:1 time with you to discuss.
The goal is to have APCM payment models be more aligned with groups that are working with an ACO or alternative payment models. If you are participating with one of these full risk programs, it is more likely that your “spend” will be more aligned with patients who need access to care rather than minutes spent.
We would welcome the opportunity to provide a side-by-side analysis of both options. APCM is not the right fit for everyone, and traditional CCM/RPM may be the right choice for now.
As these are new codes, we have not finalized our pricing for our clients. The pricing will be based on structure and care delivery for each tier of patient attribution. For groups that need access to population health tools, we will include the cost of those tools in our pricing
Yes, RPM requirements have remained the same year over year and can (and in many cases, should) be paired with APCM. These services are not considered duplicative.
There has been no guidance on any changes to MVP reporting at this time. Normal deductibles and copays still apply.
The essence of these codes is that there are no outreach requirements, these are not time-based codes, but the intent is to allow for the right care for the right patient, at the right time. More meaningful interventions for patients as needed is the overall goal. This is how we’ve always defined care management and are excited for these new payment models.
APCM codes are not replacing existing CCM codes – both code sets will continue to exist. However, for a given patient. Providers will need to choose if they would like enter the APCM model and then report that election to Medicare.
Providers need to demonstrate that they have all service elements available for their patients. Then document consent, care plans, service logs, and ongoing reviews. Care plans should include details of chronic disease management, preventative care, patient engagement activities, etc., and service logs should track services provided, including communication and coordination efforts. Our care management services provide all the care coordination and patient management and outreach. We work in coordination with your practice staff to provide a seamless care experience for your patients and document the care for billing.
Our software creates patient care plans based on medical condition, provider direction, and patient center goals. Care plans are built from our robust set of evidence based clinical goal templates and protocols built in. These protocols are adapted for each practice.. Our clinical teams create and manage to the care plan, using assessments, goal tracking and tasking to coordinate care.
No, APCM can be billed by any qualified healthcare professional who serves as the focal point for all needed health care services and is responsible for a patient’s primary care. This includes primary care physicians, family medicine practitioners, internal medicine physicians, geriatricians, and qualified advanced practice providers (NPs, PAs).
APCM has a single-provider billing requirement, it will be based on the providers’ NPI and will be provider-choice to bill for APCM or CCM.
As these are Medicare HCPCS codes, they are specifically designed for Medicare billing. However, commercial payers may choose to recognize and reimburse for these codes – similar to how many commercial plans currently cover CCM services. Final payment rates will be published when CMS releases the final fee schedule conversion factor in January 2025. 2025 Fee schedule has not been finalized yet. Pay rates were indicated within the CMS final rule published November 1st. The three new HCPCS codes for APCM are primarily designed for Medicare billing and are not mandated for use by commercial payers. Commercial payers may choose to adopt these codes, but it’s not guaranteed.
Medicare Advantage plans have to follow the Medicare fee-for-service codes, unless they are providing those services themselves. But, just like traditional CCM, if the MA plan can prove to Medicare that they are providing these services, there could be a carve out or denial for coverage.
Mental health assessments are an integral part of APCM services and can be performed as needed without specific time requirements. Unlike current care management codes, APCM eliminates the need to track time spent on these assessments, focusing instead on completing necessary evaluations and implementing appropriate follow-up care. These assessments do not affect the ability to separately bill for Behavioral Health Integration (BHI) services when appropriate, allowing practices to provide comprehensive mental health care as part of their regular care management activities.
These codes do not need to be paired with any office visit codes; they do not need a modifier and are billed separately. Based on what we’ve read in the final rule so far, these codes will be billed monthly at the beginning of the month vs. the end of the month like CCM. Our integration will create claims directly in the EHR and provide necessary compliance documentation for each claim.
Practices who are participating in MIPS will already be meeting the analytics requirements for these codes. The value pathways and gaps in care can be utilized to direct care for patients, and support MIPS goals and rewards.
Starting with Chronic Care Management (CCM) now and transitioning to Advanced Primary Care Management (APCM) when it becomes available in 2025 can be a sound strategy. APCM builds on and incorporates elements of existing care management programs, including CCM, so the experience your practice gains with CCM workflows and documentation will help prepare you for APCM implementation. APCM eliminates many administrative burdens that exist with CCM, such as time-tracking requirements, and bundles together services that were previously billed separately.
MD Revolution will manage the entire transition process from CCM to APCM for your patients, ensuring a seamless experience for both your practice and patients. Our care teams, who already have established relationships with your CCM patients, will handle all outreach and education about the enhanced APCM services during their regular patient interactions. We will obtain and document the required APCM consent, and explain the expanded benefits, while emphasizing the continued relationship with your practice as their primary care provider.
Have further questions? Get in touch.
Join MD Revolution for an introductory session on Medicare’s new Advanced Primary Care Management (APCM) payment model, proposed to launch in 2025, and how analytics data can drive care management and patient outcomes.
