General APCM FAQ
The goal of APCM is to transform primary care practices into data-driven care teams that leverage evidence-based protocols to deliver high-quality primary care services. Although CMS has provided the framework, successful implementation will depend on choosing the right partner, careful planning, possible workflow adjustments, and access to reporting technology.
As a primary care provider, how do you get from your current state to this desired future state? Let’s start with the basics and frequently asked questions.
What is APCM?
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.
APCM is a bundle of care management and communication technology-based services (CTBS), intended to address challenges in primary care delivery, such as fragmented care and inadequate compensation for comprehensive services. Unlike existing care management codes, there are no time-based thresholds included in APCM’s service elements.
What are “communication technology-based services”?
The Centers for Medicare & Medicaid Services (CMS) considers the following to be “communication technology-based services”:
- Virtual check-ins
- Remote evaluations of pre-recorded patient information
- Interprofessional consultations
How does APCM work?
APCM services encompass thorough patient assessments, individualized care plans, continuous care coordination, and non-visit-based care. PCPs and similar specialists can bill monthly for these services, with reimbursement determined by the complexity of each patient’s care.
How is APCM different from other care management programs?
APCM’s emphasis on continuous, comprehensive, and proactive care, coupled with its non-visit-based components and complexity-driven reimbursement, sets it apart from more traditional or condition-specific care management programs. APCM is more flexible than traditional chronic care management (CCM) and combines elements of several existing care management services, such as Transitional Care Management (TCM) and Principal Care Management (PCM).
APCM has three tiers for patients based on how much care they need: basic, complex, and high-risk care management. Each tier has its own billing code.
What are the qualifications for each of the APCM billing tiers?
The resources needed to deliver effective advanced primary care can vary significantly based on patient complexity, so choose the HCPCS code for APCM services that’s most appropriate for your patient’s medical and social complexity.
Use 1 of these 3 codes if all requirements are met:
G0556
- Clinical staff provide the APCM services
- A physician or other qualified health care professional who’s responsible for all primary care directs the clinical staff and serves as the continuing focal point for all needed health care services
- All 13 service elements, listed below under “What 13 service elements are required to bill for APCM services,” are available to consenting patients and utilized as appropriate
G0557
- The patient has 2 or more chronic conditions. These conditions must:
- Be expected to last at least 12 months or until the death of the patient
- Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
- The services include all of the requirements for code G0556
G0558
- The patient is a Qualified Medicare Beneficiary with 2 or more chronic conditions. These conditions must:
- Be expected to last at least 12 months or until the death of the patient
- Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
- The services include all of the requirements for code G0556
What is the reimbursement rate for APCM billing codes?
The approximate reimbursement rate for each of the APCM codes are:
G0556 (Level 1): $15
G0557 (Level 2): $50
G0558 (Level 3): $110
How do I check reimbursement rates for my region?
The PFS Look-up Tool is complete for all geographic indexes for CY 2025.
What is required before starting APCM services?
Beneficiary consent must be obtained and documented in the medical record, before you start APCM services. The beneficiary must be informed that they can stop services at any time, cost sharing may apply, and only one provider can provide APCM services for them during a calendar month.
What 13 service elements are required to bill for APCM services?
To bill for APCM services, you must complete these elements when they’re clinically appropriate for the individual patient (you don’t have to provide all of these services every month):
1) Obtain written or verbal consent from the patient to participate in APCM services, and document it in the patient’s medical record. You only need to get consent once.
2) Conduct an initiating visit for new patients, which is reimbursed separately. You don’t need to conduct this visit if you or another provider in your practice have:
- Seen the patient within the past 3 years
- Provided another care management service (APCM, CCM, or PCM) to the patient within the past year
- The Annual Wellness Visit (AWV) may qualify as the initiating visit if the provider that will be responsible for providing APCM care performs the AWV
3) Provide continuity of care, including:
- Real-time access to the patient’s medical information
- The ability for the patient to schedule successive routine appointments with a designated member of the care team
4) Provide 24/7 access for your patients or their caregivers with urgent needs to contact you or another member of the care team
5) Provide care delivery in alternative ways to traditional office visits, like home visits or expanded hours.
6) Provide comprehensive care management, including:
- Systemic needs assessments (medical and psychosocial)
- System-based approaches to ensure receipt of preventive services
- Medication reconciliation, management, and oversight of self-management
7) Develop, implement, revise, and maintain an electronic patient-centered comprehensive care plan. Criteria for compliant care planning includes:
- The care plan must be available within and outside the billing practice, as appropriate, to individuals involved in the patient’s care
- Members of the care team must be able to routinely access and update the care plan
- You must also give a copy of the care plan to the patient or caregiver
8) Coordinate care transitions between and among health care providers and settings, including:
- Referrals to other providers
- Follow-up after an emergency department visit
- Follow-up after discharge from a hospital, skilled nursing facility (SNF), or other health care facility
Coordination of care transitions must include:
- Timely exchange of electronic health information with other health care providers
- Timely follow-up communication (direct contact, phone, or electronic) with the patient or caregiver within 7 days of discharge from an emergency department visit, hospital, SNF, or other health care facility, as clinically indicated
9) Coordinate practitioner, home-, and community-based care. You must provide ongoing coordinating communication and documentation on the patient’s psychosocial strengths, functional deficits, goals, preferences, and desired outcomes from practitioners, home- and community-based service providers, community-based social service providers, hospitals, SNFs, and others
10) Provide enhanced communication channels and opportunities. You must:
- Offer asynchronous, non-face-to-face consultation methods other than the phone, like secure messaging, email, internet, or a patient portal
- Be able to conduct remote evaluation of pre-recorded patient information and provide interprofessional phone, internet, or electronic health record (EHR) referral services
- Be able to use patient-initiated digital communications that require a clinical decision, like virtual check-ins, digital online assessment and management, and evaluation and management (E/M) visits (or e-visits)
11) Conduct patient population data analysis to identify gaps in care.
12) Risk stratification of your patient population based on defined diagnoses, claims, or other electronic data to identify and target services to patients.
13) Measure and report performance, including assessment of primary care quality, total cost of care, and meaningful use of Certified EHR Technology (CEHRT). You can either:
- Report the Value in Primary Care MIPS Value Pathway (MVP). You’ll report performance starting in 2026 for CY 2025
- Participate in a Medicare Shared Savings Program Accountable Care Organization (ACO), Realizing Equity, Access, and Community Health (REACH) ACO, Making Care Primary model, or Primary Care First model
What organization types can provide APCM services?
APCM service codes are primarily for primary care practices like general internal medicine, family medicine, geriatric medicine, or pediatrics, federally qualified health centers (FQHCs), and rural health clinics (RHCs).
Who can bill for APCM services?
You can bill for APCM services if:
- You’re a physician or non-physician practitioner (NPP), including a nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS)
- You’re responsible for all of your patient’s primary care services
- You’re the focal point for all of your patient’s needed health care services
- You’ve obtained either written or verbal consent from your patient
APCM service codes are primarily for practitioners in primary care specialties, like general internal medicine, family medicine, geriatric medicine, or pediatrics.
Can support staff/auxiliary personnel provide APCM services?
Yes, just like Transitional Care Management (TCM), Chronic Care Management (CCM) and Behavioral Health Integration (BHI), auxiliary personnel can provide APCM services if they are incident to the professional services of the provider who bills the initiating visit (if required) and associated APCM services. APCM is a designated care management service, and auxiliary personnel work under general supervision.
Auxiliary personnel are individuals who are supervised by physicians or other billing providers to perform services incident to professional services of the provider. They:
- Can be employees, leased employees, or independent contractors of the billing provider
- Must not have been excluded from Medicare, Medicaid, or other federally funded health care programs by the Office of the Inspector General or had their Medicare enrollment revoked
- Must meet any applicable requirements to furnish “incident to” services, including licensure, imposed by the State in which they provide the services
How often can I bill for APCM services? How is billing APCM different than billing CCM?
You can bill for APCM services once per patient per calendar month. This helps remove some of the burden of billing with individual, time-based care management codes.
APCM services aren’t time based; they are based on the complexity of each patient’s care. You can bill using an APCM HCPCS code once per month when you meet the billing requirements, or in other words, on the 1st of the month.
When will APCM take effect?
The new Healthcare Common Procedure Coding System (HCPCS) codes issued for APCM took effect on January 1, 2025.
Where can I get more information?
To learn more about APCM services, visit our APCM resource center, read key takeaways from our Understanding Medicare’s New Advanced Primary Care Management webinar, or visit the CY 2025 Physician Fee Schedule Final Rule on CMS’s site.
The million-dollar question: Is my organization ready to implement APCM?
Now is the time to assess your practice readiness and plan for these changes. We can help! Let us know more about your current state (i.e. are you currently working with an ACO or an alternative payer model, what does your technology and data infrastructure look like?) and we will meet with you 1:1 to assess your organizational fit for APCM.
Webinar Questions & Answers
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.
Who is eligible for these G codes?
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
Can you address how Medicare is not extending reimbursement for most telehealth visits and how it affects this APCM model and care delivery?
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.
If we have an ACO + RPM in place, is this still useful?
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.
When will APCM programs be offered by MD Revolution?
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.
Are there location specific limitations in this code? For example, can it be billed for patients in a SNF or LTC?
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.
What documentation is needed to bill APCM codes? Will the payment be based on the performance measurement?
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.
Where do you pull data from to do the analytics? Claims? Do you have access to EPIC? How real time is the data you use?
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.
Is APCM similar to ACO in the way that once a patient consents for one particular APCM practice, they cannot be in another APCM program?
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.
Could these codes be used with FQHC or should FQHC still go with G0511?
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.
Any issues with billing for these being a member of an ACO?
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.
While APCM seems like the right shift, when we review the proposed payment rates for APCM, fee for service payments (what we continue to use) still seem to be significantly higher than APCM. Do you have insight into if this is a general experience for health care systems? And why might that be?
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.
What is your pricing for APCM?
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
Will RPM programs remain the same and we will be offering APCM with RPM?
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.
Do ACOs have to change to MVP reporting? Do patients have a co-pay on the PMPM?
There has been no guidance on any changes to MVP reporting at this time. Normal deductibles and copays still apply.
What type of outreach is required to bill the APCM codes?
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.
Are the APCM codes replacing existing CCM codes or are these codes in addition to the CCM codes? Would you still be able to bill CCM services in addition to the APCM codes?
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.
What kind of data does a PCP need to provide? What part can you do?
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.
Do you have care plan templates?
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.
Is there anything that makes a primary care practice/provider NOT eligible? For example, for a practice doing ACO, MIPS, PCHM, or payer quality programs, are they excluded from being eligible?
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).
For the G codes, I believe they are billed monthly to Medicare. Is this by the practice or an individual provider?
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.
Are the 3 new HCPCS codes ONLY allowed to be billed to Medicare and not to commercial payers? How did we derived the pay rates since the rates are not available on the CMS price look up tool? What about Medicare Advantage plans?
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.
To what extent could a mental health assessment be considered a part of the services (and not time spent) that qualify for these codes?
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.
Do you know which G codes are to be paired with E/M codes? Ex. G0556 should be coded with 99213?
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.
How will APCM affect MIPS?
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.
If we are ready to start with CCM, are we able to transition to APCM later?
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.
How do you handle existing CCM patients in a change to APCM?
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.
