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Remote Patient Monitoring & Chronic Care Management News

APCM FAQs for Practitioners

2 years ago

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

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.