CMS Bolsters Primary Care with Advanced Primary Care Management Coverage

Firm Publication

On November 1, the Centers for Medicare & Medicaid Services (CMS) filed its Medicare Physician Fee Schedule (PFS) final rule (Final Rule) for calendar year (CY) 2025. As part of the Final Rule, CMS finalized Medicare coverage of advanced primary care management (APCM) services through three new HCPCS codes.

By covering APCM services, CMS aims to support primary care in accordance with the Department of Health Human Services Initiative to Strengthen Primary Care. The APCM services incorporate elements of several existing care management services, including chronic care monitoring (CCM), transitional care management (TCM), and principal care management (PCM). However, unlike existing care management codes, there are no time-based thresholds that a practitioner must meet each month in order to bill these codes.

According to CMS, due in part to their time-based requirements, there has been limited uptake of care management services, and Medicare still overwhelmingly pays for primary care through traditional office/outpatient (O/O) Evaluation and Management (E/M) visit codes. The APCM services aim to encompass a broader range of services, many of which primary care practices are already providing.

Overall, CMS hopes that by reducing the administrative burden associated with current care management codes and providing more flexibility to maintain care management infrastructure, primary care practices will be able to improve patient outcomes and bring down the cost of care.

The New APCM HCPCS Codes

The new APCM codes are stratified into the following three levels based on an individual’s number of chronic conditions and status as a Qualified Medicare Beneficiary, reflecting the patient’s medical and social complexity.

  • Level 1 (G0556) is for persons with no more than one chronic condition.
  • Level 2 (G0557) is for persons with two or more chronic conditions.
  • Level 3 (G0558) is for persons with two or more chronic conditions and status as a Qualified Medicare Beneficiary (QMB).

Note that a Qualified Medicare Beneficiary (QMB) is a low income Medicare beneficiary who qualifies to receive assistance from Medicaid with their Medicare premiums, deductibles, copayments, and coinsurance. CMS indicated that “QMBs are the largest eligibility group within the Medicare-Medicaid dually eligible enrollee population, comprising of 66 percent of the 12.8 million individuals per the most recent available data…”

Requirements to Bill for APCM Services

APCM services may only be billed once per month and by one practitioner. The services must be billed by a physician or non-physician practitioner (nurse practitioner, physician assistant, certified nurse midwife, or clinical nurse specialist) who intends to be responsible for a patient’s primary care and to serve as the focal point for all of a patient’s needed healthcare services. APCM services are designated care management services, meaning they can be performed by auxiliary personnel under the general supervision of the billing practitioner.

All APCM services must include the following service elements, as appropriate during a calendar month:

  • Patient Consent. A beneficiary must be informed that: (1) APCM services are available; (2) only one practitioner can furnish and be paid for these services during a calendar month; (3) the beneficiary has the right to stop services at any time (effective at the end of the calendar month); and (4) cost sharing may apply. The practitioner should also inform the beneficiary that, by providing APCM services, they intend to assume responsibility for all of the patient’s primary care services and serve as the continuing focal point for all needed healthcare services. Patient consent is not required to be in writing but must be documented in the medical record.
  • Initiating Visit. An initiating visit with the billing practitioner is required for all new patients, i.e., patients who do not qualify as an established patient. A patient qualifies as an established patient if he or she has been seen by the billing practitioner or another practitioner in the same practice within the past three years or if the beneficiary received another care management service (such as APCM, CCM, or PCM) within the previous year from the billing practitioner or another practitioner in the same practice. In addition, CMS noted that any beneficiary eligible to be assigned to an accountable care organization (ACO) because of an established care relationship with the practitioner billing for APCM services (e. through the Shared Savings Program, ACO REACH, Making Care Primary, or Primary Care First) would not be considered a new patient and would not require an initiating visit. Services that can qualify as the initiating visit for a new patient include level 2 through 5 E/M visits, initial preventive physician exam, annual wellness visit, or transition care management services. The initiating visit can be provided in person or via telehealth.
  • 24/7 Access to Care. A practice must provide 24/7 access to the care team or a practitioner to discuss urgent care needs. In addition, a practice must be able to deliver care in alternative ways to traditional office visits to best meet patient needs, such as e-visits, home visits, and/or expanded hours. Although CMS decided not to require 24/7 real-time access to the patient’s medical record for after-hours responders, they must document and communicate their interaction with the patient to the care team/practitioner and in the patient’s medical record.
  • Continuity of Care. There must be a designated member of the care team with whom the patient is able to schedule successive routine appointments.
  • Comprehensive Care Management. The services must include comprehensive care management, which may include systematic medical and psychosocial needs assessments; system-based approaches to ensure timely receipt of all recommended preventive care services; and medication reconciliation, management and oversight of self-management.
  • Comprehensive Care Plan. A patient-centered comprehensive care plan must be developed, implemented, revised, and maintained for each patient. The care plan should be patient-friendly, timely available to individuals involved in a beneficiary’s care, and provided to the beneficiary or caregiver. The care plan can be drafted by a member of the care team, but it must be reviewed and approved by the APCM billing practitioner.
  • Management of Care Transitions. A practice must ensure the timely exchange of electronic health information with other providers. The care team or billing practitioner should follow up with the patient and/or caregiver within seven days after each emergency department visit and hospital discharge. CMS clarified that it requires reasonable efforts to reach the patient/caregiver and that any interaction should be documented in the patient’s medical record.
  • Practitioner, Home, and Community Based Care Coordination. There must be ongoing communication and coordination of needed services from practitioners, home and community-based service providers, and facilities. Communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes must be documented in a patient’s medical record. If applicable, interprofessional consultation codes (CPT codes 99446-99449 and 99451) may be billed concurrently with APCM services.
  • Enhanced Communication Opportunities. There must be enhanced opportunities for the beneficiary and/or caregiver to communicate with the care team through asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, or patient portal, including remote evaluation of pre-recorded patient information and interprofessional referral services. In addition, there may be access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and E/M visits.
  • Patient Population-Level Management. The care team must: (1) analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; and (2) risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients.
  • Performance Measurement. The practice must engage in performance assessment, including quality, cost of care, and meaningful use of certified electronic health records technology. Practitioners who are MIPS-eligible clinicians must register for and report the Value in Primary Care MVP for the performance year in which they bill for APCM services. Practitioners who are part of a TIN that is participating in a Shared Savings Program ACO or a REACH ACO, or in a Primary Care First or Making Care Primary practice would meet these requirements by virtue of meeting requirements under their model. However, CMS opted not to apply these performance measurement requirements to practitioners who are not MIPS-eligible at this time.

Not all service elements referenced above must be furnished each month in order to bill APCM services. CMS explained that “APCM services are largely designed to be person-centered and focused on the individual patient need.” CMS stated it anticipates that all APCM scope of service elements will be routinely provided, but that not all elements may be necessary for every patient during each month. By billing for APCM services, a practitioner is attesting that it meets the requirements included in the code descriptor.

Concurrent Services

Notably, CMS initially proposed that APCM services could not be billed for a patient by the same practitioner or another practitioner within the same practice concurrent with the following services: CCM, PCM, TCM, interprofessional consultation, remote evaluation of patient videos/images, virtual check-in, and e-visits.

However, CMS acknowledged in the Final Rule that APCM services are not necessarily duplicative of CCM, PCM, TCM, interprofessional consultation, remote evaluation of patient videos/images, virtual check-in, or e-visit services when billed by another practitioner in the same practice as the practitioner who is billing for APCM services. As a result, in the final rule, CMS limited the concurrent billing restrictions only to the one practitioner who is furnishing APCM services.

Please contact the authors if you have any questions related to reimbursement for APCM services.

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Firm Publication

On November 1, the Centers for Medicare & Medicaid Services (CMS) filed its Medicare Physician Fee Schedule (PFS) final rule (Final Rule) for calendar year (CY) 2025. As part of the Final Rule, CMS finalized Medicare coverage of advanced primary care management (APCM) services through three new HCPCS codes.

By covering APCM services, CMS aims to support primary care in accordance with the Department of Health Human Services Initiative to Strengthen Primary Care. The APCM services incorporate elements of several existing care management services, including chronic care monitoring (CCM), transitional care management (TCM), and principal care management (PCM). However, unlike existing care management codes, there are no time-based thresholds that a practitioner must meet each month in order to bill these codes.

According to CMS, due in part to their time-based requirements, there has been limited uptake of care management services, and Medicare still overwhelmingly pays for primary care through traditional office/outpatient (O/O) Evaluation and Management (E/M) visit codes. The APCM services aim to encompass a broader range of services, many of which primary care practices are already providing.

Overall, CMS hopes that by reducing the administrative burden associated with current care management codes and providing more flexibility to maintain care management infrastructure, primary care practices will be able to improve patient outcomes and bring down the cost of care.

The New APCM HCPCS Codes

The new APCM codes are stratified into the following three levels based on an individual’s number of chronic conditions and status as a Qualified Medicare Beneficiary, reflecting the patient’s medical and social complexity.

  • Level 1 (G0556) is for persons with no more than one chronic condition.
  • Level 2 (G0557) is for persons with two or more chronic conditions.
  • Level 3 (G0558) is for persons with two or more chronic conditions and status as a Qualified Medicare Beneficiary (QMB).

Note that a Qualified Medicare Beneficiary (QMB) is a low income Medicare beneficiary who qualifies to receive assistance from Medicaid with their Medicare premiums, deductibles, copayments, and coinsurance. CMS indicated that “QMBs are the largest eligibility group within the Medicare-Medicaid dually eligible enrollee population, comprising of 66 percent of the 12.8 million individuals per the most recent available data…”

Requirements to Bill for APCM Services

APCM services may only be billed once per month and by one practitioner. The services must be billed by a physician or non-physician practitioner (nurse practitioner, physician assistant, certified nurse midwife, or clinical nurse specialist) who intends to be responsible for a patient’s primary care and to serve as the focal point for all of a patient’s needed healthcare services. APCM services are designated care management services, meaning they can be performed by auxiliary personnel under the general supervision of the billing practitioner.

All APCM services must include the following service elements, as appropriate during a calendar month:

  • Patient Consent. A beneficiary must be informed that: (1) APCM services are available; (2) only one practitioner can furnish and be paid for these services during a calendar month; (3) the beneficiary has the right to stop services at any time (effective at the end of the calendar month); and (4) cost sharing may apply. The practitioner should also inform the beneficiary that, by providing APCM services, they intend to assume responsibility for all of the patient’s primary care services and serve as the continuing focal point for all needed healthcare services. Patient consent is not required to be in writing but must be documented in the medical record.
  • Initiating Visit. An initiating visit with the billing practitioner is required for all new patients, i.e., patients who do not qualify as an established patient. A patient qualifies as an established patient if he or she has been seen by the billing practitioner or another practitioner in the same practice within the past three years or if the beneficiary received another care management service (such as APCM, CCM, or PCM) within the previous year from the billing practitioner or another practitioner in the same practice. In addition, CMS noted that any beneficiary eligible to be assigned to an accountable care organization (ACO) because of an established care relationship with the practitioner billing for APCM services (e. through the Shared Savings Program, ACO REACH, Making Care Primary, or Primary Care First) would not be considered a new patient and would not require an initiating visit. Services that can qualify as the initiating visit for a new patient include level 2 through 5 E/M visits, initial preventive physician exam, annual wellness visit, or transition care management services. The initiating visit can be provided in person or via telehealth.
  • 24/7 Access to Care. A practice must provide 24/7 access to the care team or a practitioner to discuss urgent care needs. In addition, a practice must be able to deliver care in alternative ways to traditional office visits to best meet patient needs, such as e-visits, home visits, and/or expanded hours. Although CMS decided not to require 24/7 real-time access to the patient’s medical record for after-hours responders, they must document and communicate their interaction with the patient to the care team/practitioner and in the patient’s medical record.
  • Continuity of Care. There must be a designated member of the care team with whom the patient is able to schedule successive routine appointments.
  • Comprehensive Care Management. The services must include comprehensive care management, which may include systematic medical and psychosocial needs assessments; system-based approaches to ensure timely receipt of all recommended preventive care services; and medication reconciliation, management and oversight of self-management.
  • Comprehensive Care Plan. A patient-centered comprehensive care plan must be developed, implemented, revised, and maintained for each patient. The care plan should be patient-friendly, timely available to individuals involved in a beneficiary’s care, and provided to the beneficiary or caregiver. The care plan can be drafted by a member of the care team, but it must be reviewed and approved by the APCM billing practitioner.
  • Management of Care Transitions. A practice must ensure the timely exchange of electronic health information with other providers. The care team or billing practitioner should follow up with the patient and/or caregiver within seven days after each emergency department visit and hospital discharge. CMS clarified that it requires reasonable efforts to reach the patient/caregiver and that any interaction should be documented in the patient’s medical record.
  • Practitioner, Home, and Community Based Care Coordination. There must be ongoing communication and coordination of needed services from practitioners, home and community-based service providers, and facilities. Communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes must be documented in a patient’s medical record. If applicable, interprofessional consultation codes (CPT codes 99446-99449 and 99451) may be billed concurrently with APCM services.
  • Enhanced Communication Opportunities. There must be enhanced opportunities for the beneficiary and/or caregiver to communicate with the care team through asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, or patient portal, including remote evaluation of pre-recorded patient information and interprofessional referral services. In addition, there may be access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and E/M visits.
  • Patient Population-Level Management. The care team must: (1) analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; and (2) risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients.
  • Performance Measurement. The practice must engage in performance assessment, including quality, cost of care, and meaningful use of certified electronic health records technology. Practitioners who are MIPS-eligible clinicians must register for and report the Value in Primary Care MVP for the performance year in which they bill for APCM services. Practitioners who are part of a TIN that is participating in a Shared Savings Program ACO or a REACH ACO, or in a Primary Care First or Making Care Primary practice would meet these requirements by virtue of meeting requirements under their model. However, CMS opted not to apply these performance measurement requirements to practitioners who are not MIPS-eligible at this time.

Not all service elements referenced above must be furnished each month in order to bill APCM services. CMS explained that “APCM services are largely designed to be person-centered and focused on the individual patient need.” CMS stated it anticipates that all APCM scope of service elements will be routinely provided, but that not all elements may be necessary for every patient during each month. By billing for APCM services, a practitioner is attesting that it meets the requirements included in the code descriptor.

Concurrent Services

Notably, CMS initially proposed that APCM services could not be billed for a patient by the same practitioner or another practitioner within the same practice concurrent with the following services: CCM, PCM, TCM, interprofessional consultation, remote evaluation of patient videos/images, virtual check-in, and e-visits.

However, CMS acknowledged in the Final Rule that APCM services are not necessarily duplicative of CCM, PCM, TCM, interprofessional consultation, remote evaluation of patient videos/images, virtual check-in, or e-visit services when billed by another practitioner in the same practice as the practitioner who is billing for APCM services. As a result, in the final rule, CMS limited the concurrent billing restrictions only to the one practitioner who is furnishing APCM services.

Please contact the authors if you have any questions related to reimbursement for APCM services.

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