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Advanced Primary Care Management (APCM) Resource Center

CoachCare + Advanced Primary Care Management (APCM)

CMS’s Advanced Primary Care Management (APCM) program gives practices a new way to deliver coordinated, relationship-driven care while strengthening reimbursement. CoachCare helps practices operationalize APCM through integrated technology, patient engagement tools, and clinical support designed to extend care beyond the office visit. With more than 1,000 implementations and 500,000+ patients served, CoachCare helps practices launch and scale APCM with confidence.

Our Expertise

CoachCare brings deep expertise in CMS program implementation, having helped practices nationwide succeed with chronic care management, remote patient monitoring, principal care management and other programs. Our comprehensive understanding of CMS requirements, combined with our proven platform technology, positions us uniquely to support your APCM implementation.

Comprehensive Implementation Support

We offer practices a complete suite of services to ensure APCM success:

• Full APCM readiness assessment and gap analysis
• Custom implementation strategy and timeline development
• Complete technology setup and EHR integration
• Staff training and workflow optimization
• Ongoing support and program optimization
• Performance monitoring and quality improvement

Long-Term Partnership

From initial implementation to providing ongoing clinical care services to support APCM and your practice, CoachCare serves as your ongoing partner in APCM success. We continuously monitor regulatory changes, update best practices, and provide optimization recommendations to ensure your practice maximizes both patient outcomes and financial returns.

Getting Started

Let CoachCare help determine if APCM is right for your practice and create a customized implementation plan. Contact our team today to schedule a personalized consultation and learn how we can support your transition to advanced primary care management.

Introduction to Advanced Primary Care Management (APCM)

Advanced Primary Care Management (APCM) is an innovative program established by the Centers for Medicare & Medicaid Services (CMS) in 2025. APCM was launched to address longstanding challenges in primary care delivery, including fragmented care, inadequate compensation for comprehensive services, and the need to better support practices in managing complex patient populations and social determinants of health.

At its core, APCM strengthens the infrastructure behind primary care—giving practices the tools, workflows, and reimbursement framework to better support patients between visits, improve continuity, and manage population health at scale.

With APCM, practices can:

• Proactively manage patient populations and identify care gaps
• Strengthen preventive and chronic care management workflows
• Expand patient access through flexible care delivery models
• Support better long-term outcomes through engagement beyond the visit

CoachCare helps practices bring these capabilities into everyday care delivery through integrated technology, patient engagement tools, and clinical support designed to extend care beyond the office visit.

Overview and Purpose of Advanced Primary Care Management

Advanced Primary Care Management aims to strengthen primary care by recognizing and supporting comprehensive, longitudinal care management. Unlike traditional fee-for-service models, APCM bundles various care management services into a single monthly payment. This approach allows practices to focus on delivering high-quality, patient-centered care without the burden of tracking multiple billing codes.

Key objectives of APCM include:

• Enhancing care coordination and continuity
• Promoting team-based care delivery
• Addressing patients’ medical and social needs holistically
• Reducing administrative complexities for providers
• Aligning payment with the value of comprehensive primary care

APCM Codes and Payment Levels

Unlike traditional care management programs, APCM is not time-based, giving practices greater flexibility to deliver care in the ways that best support their patient population.

CMS established three APCM HCPCS codes to support varying levels of patient complexity. Together, these codes create a monthly reimbursement pathway for delivering longitudinal, relationship-based primary care services across the Medicare population.

• G0556: For patients with one or fewer chronic conditions. Approximate reimbursement: $16-20 PMPM
• G0557: For patients with two or more chronic conditions. According to CMS, nearly four in five Medicare beneficiaries have two or more chronic conditions. Approximate reimbursement: $50-54 PMPM
• G0558: For Qualified Medicare Beneficiaries with two or more chronic conditions. Approximate reimbursement: $107-117 PMPM

These tiered payments recognize that patients with multiple chronic conditions or social risk factors require more intensive care management.

National average Medicare reimbursement shown. Actual payment varies by geography and payer.

Service Elements and Requirements

Advanced Primary Care Management (APCM) includes 13 core service elements that build upon existing Chronic Care Management (CCM) and Principal Care Management (PCM) services. APCM emphasizes the capabilities needed to deliver advanced primary care while allowing practices to tailor services to individual patient needs.

1. Patient Consent: Inform the patient about the service, obtain consent, and document it in the medical record.
2. Initiating Visit: for new patients or those not seen within three years.
3. 24/7 Access: Provide 24/7 access for urgent needs to the care team/practitioner.
4. Continuity of Care: Ensure continuity with a designated team member for successive routine appointments.
5. Alternative Care Delivery: Offer care through methods beyond traditional office visits, such as e-visits, phone visits, home visits, and extended hours.
6. Comprehensive Care Management: Care management is a resource-intensive process of working with patients, generally outside of face-to-face office visits.
7. Electronic Care Plan: Develop and maintain a comprehensive care plan accessible to the care team and patient.
8. Care Transitions Coordination: Facilitate transitions between healthcare settings and providers, ensuring timely follow-up communication.
9. Ongoing Communication: Coordinate with various service providers and document communications about the patient’s needs and preferences.
10. Enhanced Communication Methods: Enable communication through secure messaging, email, patient portals, and other digital means.
11. Population Data Analysis: Use data to develop clear improvement strategies and analytic processes.
12. Risk Stratification: Use data to identify and risk-stratify the practice population.
13. Performance Measurement: Assess quality of care, total cost of care, and use of Certified EHR Technology.

CoachCare’s remote care management platform is well-positioned to support APCM implementation, aligning closely with the program’s key elements. Our solutions support timely access to care team support, comprehensive care management, and population health analytics aligned to APCM requirements.

Eligibility and Implementation

Who Can Participate

Providers

APCM services can be billed by physicians and qualified healthcare professionals who serve as the focal point for all needed health care services.

Patients

Medicare beneficiaries are eligible for APCM services.

Attribution Process

Patient attribution in APCM is intended to be based on patient choice and documented consent. Patients must provide consent to receive APCM services from a specific provider.

Technology Requirements

To participate in APCM, practices must have certain technological capabilities:

• Certified Electronic Health Record (EHR) Technology
• Population Health Management Tools
• Secure Communication Platforms
• Data Analytics Capabilities

CoachCare’s comprehensive platform has been designed and stands ready to meet these technology requirements.

Performance Measurement and Reporting

APCM performance measurement focuses on quality of care, patient outcomes, total cost of care, and the use of Certified EHR Technology. Performance measurement activities may include:

• Cancer screening and immunization tracking
• Blood pressure and chronic disease management

CoachCare supports APCM performance measurement through integrated reporting, data access, population health analytics, and actionable care insights.

Comparison and Context

Benefits of APCM:

• Simplified billing through a monthly reimbursement structure
• Support for proactive, population-based care management
• Improved continuity of care and patient engagement

Considerations for Implementation:

• Practice workflow design and operational readiness
• Patient consent and attribution tracking

How APCM Relates to Other Care Management Programs

APCM expands on many CCM service elements but is billed through a monthly APCM code structure rather than time-based care management billing.

CoachCare supports practices through that evaluation—helping teams align clinical workflows, care management services, and reimbursement strategy under APCM.

Resources and Support

Official CMS Documents

For the most up-to-date and authoritative information on APCM, refer to these official CMS resources.

Industry Analyses and Commentary

Additional APCM implementation guidance, reimbursement updates, and policy analysis can be found through various sources.

Questions & Answers

This Q&A resource compiles the key questions and answers from the webinar, covering essential topics like compliance, technology integration, and practical steps for implementing Advanced Primary Care Management.