What is Advanced Primary Care Management (APCM)?
In 2025 Medicare introduced a new Primary Care reimbursement opportunity known as Advanced Primary Care Management (APCM). In doing so Medicare now supports primary care clinics in their eventual transition to value-based care. Ultimately, Medicare’s goal is to promote longitudinal relationships between clinicians and patients while reimbursing for risk-stratified care management services.
How is APCM different from Chronic Management (CCM)?
The main differences between APCM and CCM include:
Coding is based on risk stratification and not time.
APCM utilizes 3 risk-stratified HCPCS codes
CPT G0556 applies to patients with zero or 1 chronic diseases (Tier 1). APCM services are provided by clinical staff under the supervision of a primary care physician, NP, or PAl. This clinician is responsible for delivering ongoing care management for all required healthcare services. The CMS National Payment Amount for Tier 1 APCM patients is $15.20 per patient per month with an wRVU value of 0.25.
CPT G0557 applies to patients with two or more chronic diseases (Tier 2) which are expected to continue for at least 12 months and place the patient at significant risk of death, acute exacerbation, or functional decline. The CMS National Payment Amount for Tier 2 APCM patients is $48.84 per patient per month with an wRVU value of 0.77.
CPT G0558 is similar to G0557 (i.e. meets Tier 2 criteria) but applies to any patient who is a Qualified Medicare Beneficiary (QMB + Tier 2 = Tier 3). The CMS National Payment Amount for Tier 3 APCM patients is $107.07 per patient per month with an wRVU value of 1.67.
As described by CMS, the billing primary care provider must be responsible “for all primary care and serves as the continuing focal point for all needed health care services.”
While a clinician care manager typically oversees a patient panel the billing provider provides ‘general supervision’ similar to existing care management programs.
APCM does not utilize time based billing.
There is no minimum time requirement per month, as with CCM, but instead a higher focus is placed on care gap closure, patient safety, care coordination and improving clinical outcomes while reducing the total cost of care delivery.
Participation in a quality program is required.
APCM applies to all Medicare beneficiaries.
CMS has opened APCM to available for every Medicare patient regardless of their number of chronic diseases.
APCM requires quality reporting. What does CMS require in the delivery of APCM?
APCM, unlike CCM, requires participation in a quality measurement and reporting program such as MIPS, ACO REACH , Primary Care First or Making Primary Care.
What does CMS require in the delivery of APCM?
APCM requires 13 service elements which need to be documented and performed, however not all service elements must be provided each month. It is up to the provider’s discretion which elements are needed for each patient and when they should be performed.
The 13 APCM elements include:
Patient consent: Similar to other care management programs—inform the patient about their program eligibility, possible cost-sharing, right to discontinue participation, one provider may bill per month, obtain consent which may be verbal or written with documentation of consent in their chart. APCM requires new consent and new enrollment even if they’ve participated in CCM previously.
Initiating visit: Provide an initiating visit unless the patient has been seen within three years or received other care management services (e.g. CCM) from another provider in the same practice within the previous year.
24/7 access to care: Ensure patients have immediate care access which may be via the clinic on-call phone system.
Care continuity: At least one designated care team member must provide ongoing patient contact between visits.
Patient-centered care delivery: Patients must have access to alternative care methods beyond traditional office visits, which may include home visits, expanded hours, etc.
Comprehensive care management: A team based approach is required with a focus on a systematic and proactive approach to needs assessments, preventative services, medication reconciliation, and self-management.
Comprehensive and digital care plan: Develop and maintain a comprehensive digital care plan accessible to the care team. The plan should be patient-centered and available digitally inside and outside of the billing practice.
Care transitions coordination: Timely communication, data exchange, and care coordination between healthcare settings and providers within seven days of discharge (TCM is included in APCM so can not be billed in the same month).
Practitioner, home, and community coordination: Continuous communication and coordination among different types of service providers, including social workers, home health, and care facilities. Additional focus on documenting the patient’s psychosocial and functional needs, goals, and preferences.
Enhanced communication methods: Ensuring communication between the patient or family caregiver and the care team through asynchronous, non-face-to-face methods beyond the telephone, including secure messaging, email, patient portals, and other digital means.
Population Health: Identify and close care gaps via a scalable, population health management approach to the clinic’s APCM patient panel.
Risk stratification: Perform data analytics to identify and target services to better manage high-risk patients.
Performance / Quality measurement: Document and report on quality of care performance, including total cost of care and use of Certified EHR Technology. Participation in MIPS, REACH ACO, and other primary care or shared savings programs meet quality requirements.