Subpages:
What is APCM?
Definition and Overview
Key Components of APCM
Benefits of APCM for Patients and Providers
APCM vs. Traditional Primary Care
Key Differences
Advantages of APCM over Traditional Models
Eligibility for APCM
Medicare Beneficiary Eligibility
Provider Eligibility and Qualifications
APCM Coding and Reimbursement
Table of Contents
1. What is APCM
Advanced Primary Care Management (APCM) is a Medicare initiated program to help primary care providers to deliver continuous, proactive care to patients. A strong foundational primary care system is fundamental to improving health outcomes, lower mortality, and reducing health disparities, which is why CMS has been taking action to strengthen the primary care including new coding, and payment for APCM in 2025 PFS final rule. This program helps in bridging the traditional fee for services care with value-based care and population focused care. APCM offers customized care plans for a wide range of patients' needs from low to high complexity.
2. Benefits of APCM
APCM provides many benefits for both the provider and the patient due to more continuous care.
Regular follow-up leads to improved patient care, better disease management, and a reduction in emergency room visits, which is the cornerstone of the program.
A proactive management approach leads to improved patient communication and bridging the gap between patient and providers.
Increases practice revenue streams through increased patient contact and new, monthly billing codes.
Improves efficiency and workflow when combined with other virtual care programs such as Remote Patient Monitoring (RPM) for proactive monitoring and management.
3. Key differences between APCM and other models
There are some unique differences between APCM and traditional models. The main difference between the programs like chronic care management (CCM) is ongoing general support for patients with multiple chronic conditions while APCM can be used for a wider range of patients’ needs including those with stable conditions requiring complex management. This means that APCM is available to more if not all Medicare beneficiaries. Billing codes are stratified by three corresponding risk levels, rather than by time spent.
4. Key Components
The focus of APCM is on activities and outcomes rather than time. APCM does require quality measurement reporting, by which success of the program can be determined. In addition, only primary care providers are eligible for APCM.
Due to overlap in care, CCM and APCM programs cannot be run and charged by a provider or another provider in the same practice simultaneously for a patient. Other codes that overlap include those for TCM, PCM, and 15 communication-based technology CPT codes.
Practices may enroll patients in different overlapping programs, but not at the same time.
Patients are allowed to be enrolled in support programs such as RPM , Remote Therapeutic Monitoring (RTM), Health Related Social Needs (HRSM), and Behavioral Health Integrations (BHI) which are viewed as complementary.
5. Patient Eligibility, coding, and reimbursement
APCM is stratified into three billing codes based on their overall health.
Level 1. G0556
For patients with one or even zero chronic conditions.
The patient must have been seen by the provider within the last 36 months.
$10 dollar reimbursement per patient, per month.
18% of Medicare cohort
Level 2. G0557
For patients with two or more chronic conditions.
The patient must have been seen by the provider within the last 12 months.
$50 dollar reimbursement per patient, per month.
70% of Medicare cohort
Level 3. G0558
For patients with two or more chronic conditions who are Qualified Medicare Beneficiaries (QMB)
The patient must have been seen by the provider within the last 12 months.
$110 dollar reimbursement per patient, per month
12% of Medicare cohort
Practice and Provider Eligibility
A practice and provider must also qualify for eligibility into the program. Only primary care providers are eligible to provide these services.
The provider should educate and must receive consent to enroll the patient.
The provider must also determine the APCM level of the patient and assure the patient has been seen within the allotted time frame (12 or 36 months).
The patient must have access to a 24/7 access care team.
The care team must have up-to-date access to the patient's medical record.
Auxiliary personnel that are supervised by the primary physician may provide ACPM services.
Electronic communication via telephone, secure messaging text, email, patient portal, virtual check in and visits should be used.
Each patient should receive an electronic, individual care plan.
If the physician is not primarily helping the patient, the same member of the care team must be available to the patient for subsequent appointments.
The care team will be responsible for coordinating care transitions and referrals including ER and hospital visits as well as discharges from hospitals and skilled nursing facilities.
Care should be offered in alternative ways such as after hours, telemedicine, or home visits in conjunction with community care.
Population health is necessary to develop and test population specific care.
How Enable Healthcare Inc (EHI) can help
Enable Healthcare can help guide and support your practice in APCM and value-based care programs.
Provide documentation software as well as end-to-end services
Identify and enroll eligible patients
Create and review individualized care plans
Multilingual nursing staff support
Generate billing
Dashboard and reports with CMS compliance
Help with quality / MIPS reporting
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!