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Advanced Primary Care Management (APCM) FAQs

Writer's picture: Ioannis M. Kalouris, MDIoannis M. Kalouris, MD
Jan 105 min read

Updated: Jan 21

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To learn more about Enable Healthcare’s comprehensive approach to healthcare solutions, visit Enable Healthcare's homepage.

If you have questions regarding APCM enrollment or need support, don’t hesitate to contact Enable Healthcare for further assistance.


Reimbursement and Financial Considerations


To learn more about the official CMS guidelines for APCM codes and billing, you can visit the CMS official website for the most up-to-date information.


  1. Are APCM codes time based?

    1.     No, APCM codes are not tied to time thresholds, simplifying the billing process


  1. What codes are used?

    1. G0556 for patients with one or fewer chronic conditions.

      1. Seen within the last 3 years

    2. G0557 for patients with two or more chronic conditions. 

      1. Seen within the last 1 year

    3. G0558 for Qualified Medicare Beneficiaries QMB with complex needs. 

      1. Seen within the last 1 year


  1. What is the monthly reimbursement for each code?

    1. G0556 - $15

    2. G0557 - $50

    3. G0558 - $110


  1. What is the impact of the 2025 PFS conversion factor decrease on APCM reimbursement?

    1. The conversion factor is $32.35

    2. The 2.83% reduction in the conversion factor may slightly reduce reimbursement for APCM services; however, these codes are designed to simplify care coordination, potentially offsetting this reduction.


  1. Can APCM codes be billed alongside other care management services?

    1. No, APCM codes cannot be billed concurrently with other overlapping services, such as CCM or transitional care management. 


  1. How do bundled payments work under APCM?

    1. APCM uses a monthly bundled payment model covering all eligible care management services.


  1. Are there additional incentives for rural providers in APCM?

    1. Yes, rural providers may qualify for higher reimbursement rates and expanded service eligibility.


  1. Is there any penalty for early program withdrawal

    1. No specific penalties exist, but providers must ensure compliance during participation to avoid retroactive audits. 


  1. What is the reporting frequency for APCM metrics?

    1. Providers must report quality and utilization metrics yearly to CMS. 


  1. Are there penalties for non-compliance in APCM?

    1. Yes, penalties may include recoupment of payments or disqualification from the program.


  1. Can practices participate in both APCM and accountable care organizations (ACOs)?

    1.    Yes, APCM aligns with ACO goals, making dual participation possible.


If you’re interested in dual participation in APCM and ACOs, it's important to refer to the CMS regulations to verify your eligibility and program requirements.


  1. Are private payers adopting similar APCM models?

    1. Some private insurers are exploring similar models to align with Medicare's APCM framework.


  1. Can APCM services overlap with Annual Wellness Visits?

    1. APCM codes can be reported with preventative services such as AWVs. 


  1. Can APCM be billed for patients in hospice care?

    1. No, APCM services are not eligible for patients receiving hospice or similar end-of-life care.


Program Design and Goals


  1. What patient engagement tools are recommended for APCM?

    1. Providers must use certified EHR systems to document care and services.

    2. Virtual engagement tools like patient portals, health monitoring apps, and secure messaging platforms are necessary and encouraged to improve engagement.


  1. What is the role of interdisciplinary teams in APCM?

    1. Teams may include physicians, nurses, social workers, and pharmacists to provide holistic care.


  1. Does APCM include 24/7 access to care?

    1. Yes, it requires 24/7 urgent care access for patients, including the ability to contact healthcare professionals.


  1. Can APCM services be outsourced to third-party vendors?

    1. Yes, provided vendors comply with CMS guidelines and work under the supervision of qualified providers. 


  1. How does APCM align with value-based care models?

    1. APCM integrates value-based care principles by emphasizing outcomes, cost efficiency, and patient satisfaction.


  1. How does APCM promote chronic disease management?

    1. APCM supports regular check-ins, medication adherence monitoring, and more frequent care plan adjustments tailored to patient needs.


  1. How does CMS define "care coordination" under APCM?

    1. Care coordination includes managing referrals, communicating with other providers, and aligning care across settings.


  1. How does APCM address health disparities?

    1. APCM emphasizes proactive care in underserved areas, with an aim to reduce disparities in chronic condition outcomes.


  1. What is the expected long-term impact of APCM?

    1.     APCM aims to improve patient satisfaction, reduce hospitalizations, and lower total healthcare costs.


  1. What measures are used to evaluate APCM success?

    1.     Measures include patient satisfaction, health outcomes, and cost savings.


Eligibility and Enrollment

  1. How are patients identified for APCM enrollment?

    1. Patients with one or more chronic conditions, recent hospitalizations, or high-risk indicators are prioritized.


  1. What is the policy for dual-eligible beneficiaries in APCM?

    1. APCM includes dual-eligible beneficiaries, with services coordinated across Medicare and Medicaid.


  1. Is APCM mandatory for eligible providers?

    1. No, participation is voluntary but encouraged for practices looking to improve care coordination. 


  1. What are the eligibility criteria for providers in APCM?

    1. Eligible providers include physicians, nurse practitioners, clinical nurse specialists, and physician assistants participating in primary care.


  1. How often must providers renew their APCM participation?

    1. Providers typically renew annually by updating their enrollment information with CMS.


  1. Are there specific requirements for FQHCs and RHCs in APCM?

    1. Yes, these facilities must meet additional care coordination and reporting standards. 

    2. Previously G0511 served for multiple services including CCM and RPM.

    3. CMS is proposing three new G-codes to simplify billing and documentation requirements starting in January 2025, with a six-month transition period.


  1. Can providers with small patient panels participate in APCM?

    1. Yes, any size practice can participate, regardless of scale. 


Care Coordination and Workflow Integration

  1. What care planning requirements are included in APCM?

    1. Providers must create a comprehensive care plan, regularly updated and accessible to the care team and the patient.


  1. How does APCM support care transitions?

    1. Follow-ups within seven days of hospital discharge and coordination with specialists are integral to APCM.


  1. What data analytics are used in APCM?

    1. Practices use analytics to identify high-risk patients, track outcomes, and optimize care plans.

    2. Practices should look at both individual and community health perspectives. 


  1. What role does patient feedback play in APCM?

    1. Patient satisfaction surveys and feedback inform care plan adjustments and quality improvements.


  1. How are remote monitoring devices integrated into APCM?

    1. Remote monitoring is encouraged for chronic condition tracking and can be billed under specific codes.


Telehealth and Virtual Care

  1. Are there restrictions on telehealth use in APCM?

    1. Telehealth services must comply with CMS guidelines, including secure platforms and documentation requirements.


  1. Can APCM services be provided entirely virtually?


  1. While in-person visits are encouraged, virtual care is a key component of APCM delivery.

  2. Depending on the category, a patient must have been seen within one or three years. 

While in-person visits are encouraged, telehealth has played a vital role in expanding access to care. Explore more about virtual care developments to understand how technology continues to reshape healthcare delivery.


  1. How has telehealth expanded under the 2025 PFS?

    1. Audio-only telehealth and virtual direct supervision remain extended through 2025.


  1. What is the role of family caregivers in APCM telehealth?

    1. Family caregivers can join telehealth sessions to help ensure patient adherence and understanding.


  1. Are there any upcoming changes to telehealth reimbursement in APCM?

    1. CMS is exploring expanded reimbursement for asynchronous telehealth services starting in 2026.

Telehealth has become a critical component of APCM, and CMS continues to evolve its policies to support virtual care. To stay informed about the latest telehealth advancements, visit Healthcare IT News for ongoing updates on virtual care technologies.


  1. What safeguards are in place for telehealth in APCM?

    1. Safeguards include secure platforms, data encryption, consent documentation, and adherence to HIPAA requirements. 


  1. How are telehealth encounters reimbursed under APCM?

    1. Telehealth visits are included in the monthly APCM payment and are not separately reimbursed.


Ready to Implement APCM in Your Practice?


At Enable Healthcare, we’re here to guide you through the complexities of Advanced Primary Care Management (APCM) and help your practice deliver higher-quality, value-based care. Our team offers end-to-end support, from patient enrollment and individualized care plans to billing and compliance reporting.

Get in touch with us today to learn how we can help you optimize your APCM strategy, improve patient outcomes, and boost your practice’s revenue.

Contact Us or Schedule a Consultation to start transforming your practice with APCM today!



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