Skip to main content
Rural Health Information Hub
Rural Health Information Hub

Advanced Primary Care Management

What are Advanced Primary Care Management (APCM) services?

The Centers for Medicare & Medicaid Services (CMS) began reimbursing for Advanced Primary Care Management (APCM) services on January 1, 2025. APCM services combine elements of several existing care management and communication technology-based services you may already be providing to your patients. The APCM payment bundle includes:

APCM includes services for Medicare patients at three levels:

  • Level 1: Patients with one or fewer chronic conditions
  • Level 2: Patients with two or more chronic conditions
  • Level 3: Patients with two or more chronic conditions and who participate in the Qualified Medicare Beneficiary (QMB) program

APCM services are subject to the usual Medicare Part B cost sharing requirement.

Note that Community Health Integration and Principal Illness Navigation services can be billed concurrently with APCM, as long as time and effort are not counted more than once, requirements to bill other services are met, and the services are medically reasonable and necessary.

What are the required elements of APCM services?

APCM requires providers to complete the following elements when clinically appropriate. Not all of the following services need to be provided every single month.

  • Patient consent: The billing practitioner should get written or verbal consent from the patient to participate in APCM services and document it in the patient's medical record. The consent should note that only one practitioner can provide APCM services during the month, the patient can end APCM services at any time, and cost sharing may apply. Patient consent is only required once.
  • Initiating visit: An initiating visit, that is paid separately, is required for new patients or patients who have not been seen in the previous three years. An Annual Wellness Visit (AWV) can qualify as an initiating visit, if the provider performing the AWV will be responsible for APCM services.
  • 24/7 access and continuity of care: Patients must have 24/7 access to their provider or other member of the care team with real-time access to the patient's medical information to address urgent needs. Continuity of care includes the ability for the patient to schedule successive routine appointments with the care team. The practice should also maintain the capability to deliver care in alternative ways to traditional office visits, such as e-visits, phone visits, home visits, and/or expanded hours.
  • Comprehensive care management: Similar to CCM and PCM, comprehensive care management may include systematic medical and psychological needs assessments, system-based approaches to ensure receipt of preventive services, and medication reconciliation and oversight of a patient's self-management of medications.
  • Patient-centered comprehensive care plan: Similar to CCM and PCM, the comprehensive patient-centered care plan is an agreed upon with the patient and describes the patient's health goals, needs, and self-management activities using patient-friendly language. It should be available within and outside of the billing practice and updated as needed. A copy should also be given to the patient.
  • Management of care transitions: The billing practice should ensure timely exchange of electronic health information with other practitioners and providers. Similar to TCM, timely follow-up includes making reasonable efforts for follow-up after emergency department visits and discharges from hospitals, skilled nursing facilities (SNFs), and other health care facilities within seven days.
  • Practitioner, home-, and community-based care coordination: The billing practice should provide ongoing communication about the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, and coordination of services with practitioners, home-, and community-based providers, such as social service providers, hospitals, SNFs, and other health care facilities as needed.
  • Enhanced communication opportunities: The billing practice should offer asynchronous, non-face-to-face communication methods, such as secure messaging, email, internet, or a patient portal, communication technology-based services (e.g., remote evaluation of pre-recorded patient information, interprofessional referrals), and patient-initiated digital communications (e.g., virtual check-ins, e-visits).
  • Patient population-level management: The billing practice should proactively analyze population health data and implement strategies to improve outcomes. Data analysis should identify gaps in care and risk stratify the practice's patient population based on defined diagnoses, claims, or other data to focus services and interventions.
  • Performance measurement: The billing practice must measure and report performance on primary care quality, total cost of care, and meaningful use of CEHRT. For MIPS-eligible clinicians, this requirement can be met by reporting the Value in Primary Care MVP. Clinicians who are Qualifying APM Participants or participate in a Shared Savings Program Accountable Care Organization (ACO), Realizing Equity, Access, and Community Health (REACH) ACO, Primary Care First, or Making Care Primary models can continue to measure performance through these APMs.

Why provide APCM services?

APCM services allows your practice to provide patients with a range of care management services that meet the patients' individual needs. Additionally, the use of APCM can simplify billing and documentation as services are billed using a monthly bundle, rather than individual time-based codes.

Who can provide APCM services?

APCM services should be provided by the patient's primary care provider, meaning the provider is "responsible for all primary care and serves as the continuing focal point for all needed health care services." APCM services can be provided by a:

  • Physician
  • Nurse Practitioner
  • Physician Assistant
  • Clinical nurse specialist

In addition to physician offices, APCM services can be provided by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs).

Auxiliary personnel, such as community health workers (CHWs), nurses, or social workers, may perform APCM services incidental to the billing practitioner under general supervision. Auxiliary personnel who provide APCM services may be employed by the billing practitioner or may be external to, and under contract with, the practitioner.

What are the billing codes for APCM services?

There are three HCPCS codes for APCM services which reflect the patient's level of complexity:

  • G0556: APCM for Medicare patients with one or fewer chronic conditions (Level 1), per calendar month
  • G0557: APCM for Medicare patients with two or more chronic conditions (Level 2), per calendar month
  • G0558: APCM for Medicare patients with two or more chronic conditions who are Qualified Medicare Beneficiaries (Level 3), per calendar month

APCM cannot be billed concurrently for duplicative services, including CCM, PCM, TCM, interprofessional internet consultation, remote evaluation of patient videos/images, virtual check-ins, or online digital E/M visits (e-visits).

Note that Community Health Integration and Principal Illness Navigation services can be billed concurrently with APCM, as long as time and effort are not counted more than once, requirements to bill other services are met, and the services are medically reasonable and necessary.

How do I document APCM in my electronic health record (EHR)?

Several components of APCM must be documented in the medical record, including:

  • The patient's verbal or written consent,
  • A patient-centered comprehensive care plan, and
  • Performance measurement elements (e.g., Value in Primary Care MVP quality and outcomes measures, improvement activities, interoperability measures, and population health measures).

What are the reporting requirements for APCM services?

APCM services require the billing practitioner to participate in quality measurement and reporting. This requirement can be met for MIPS eligible clinicians by reporting the Value in Primary Care MVP beginning in the CY 2025 performance period/2027 MIPS payment year. Billing practitioners who are not MIPS eligible clinicians do have to report the MVP to provide APCM services.

Are there any special considerations for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for APCM?

RHCs and FQHCs can bill APCM codes (G0556, G0557, and G0558). The payments for these codes are the national non-facility PFS payment rates when the individual code is on an RHC or FQHC claim, either alone or with other payable services and the payment rates are updated annually based on the PFS amounts for these codes. These codes are billed per calendar month and may not be billed with individual codes for duplicative services, such as CCM, PCM, or TCM.

Resources

Last Updated: 1/14/2025
Last Reviewed: 1/14/2025