April 11, 2025
Understanding Advanced Primary Care Management and Its Relationship to Existing Care Programs
- by Doug Graham, Senior Management Consultant
The Advanced Primary Care Management (APCM) model represents a transformative approach to care management, offering a more flexible and comprehensive payment structure for primary care practices. By building upon existing programs such as Chronic Care Management (CCM), APCM simplifies reimbursement while enhancing care coordination. This document explores the key components of APCM, its tiered payment structure, and how it integrates with or replaces current care management services. It also outlines the essential service elements required for billing under APCM and the impact on practice workflows, ensuring providers can optimize patient care while maintaining compliance with Medicare’s evolving policies.
Stable Revenue Stream and Financial Flexibility
The APCM model payments provide a stable revenue stream to support infrastructure and enhanced services. These prospective payments enable care management and coordination, giving practices financial flexibility to develop capabilities that meet patient needs.
General Supervision and Non-Time-Based Codes
APCM services can be provided under general supervision, qualifying as a “designated care management service” under § 410.26(b)(5). Unlike current care management services, APCM codes are not time-based, reflecting that care management is a standard part of advanced primary care, even when documented staff time does not meet traditional billing thresholds.
Removal of Timeframe Restrictions
APCM also removes timeframe restrictions in existing communication technology-based services codes. The new G0556, G0557, and G0558 codes eliminate limitations related to E/M services, allowing greater flexibility in service delivery.
New APCM HCPCS G-Codes
CMS has established three HCPCS G-codes based on patient complexity, ensuring reimbursement for all Medicare beneficiaries:
- G0556: For patients with one or fewer chronic conditions. Proposed value: 0.17 RVUs (~$15/month).
- G0557: For patients with two or more chronic conditions (80% of Medicare beneficiaries). Proposed value: 0.77 RVUs (~$50/month).
- G0558: For Qualified Medicare Beneficiaries (QMBs) with two or more chronic conditions. Proposed value: 1.67 RVUs (~$110/month).
These tiered payments account for patients needing intensive care management due to chronic conditions or social risk factors.
Service Elements and Requirements
APCM builds upon Chronic Care Management (CCM) services, eliminating time-tracking requirements and allowing comprehensive care delivery. Practices must demonstrate capabilities in the following areas:
Core APCM Service Elements
- Patient Consent: Inform the patient, obtain consent, and document it. The practitioner assumes responsibility for all primary care services.
- Initiating Visit: Required for new patients or those not seen within three years.
- 24/7 Access: Provide real-time access to urgent care needs, including after-hours contact options via nurse call lines, answering services, or partnerships with urgent care providers.
- Continuity of Care: Ensure continuity with a designated team member for routine appointments. This includes relational (ongoing therapeutic relationship), informational (access to patient history), and longitudinal (ongoing care patterns) continuity.
- Alternative Care Delivery: Offer care beyond office visits, such as e-visits, phone visits, home visits, or extended hours to meet patient needs.
- Comprehensive Care Management: Engage in resource-intensive processes outside of office visits, including:
- Conducting systematic needs assessments.
- Ensuring preventive service receipt.
- Medication reconciliation and oversight of self-management.
Electronic Care Plan
Maintain a comprehensive, accessible care plan, including:
- Problem list, expected outcomes, and treatment goals.
- Cognitive, functional, and symptom assessments.
- Interventions, medical management, and caregiver assessments.
- Coordination with outside providers and periodic plan reviews.
Care Transitions Coordination
Facilitate transitions between care settings with timely follow-ups, particularly after hospital discharges or ED visits.
Ongoing Communication
Coordinate and document communications with specialists and community providers to manage referrals and social needs assessments.
Enhanced Communication Methods
Enable secure messaging, email, and patient portal use.
Population Data Analysis
Use data analytics to improve population health management and identify care gaps. Participants in Shared Savings Program ACO, REACH ACO, Making Care Primary, or Primary Care First already meet this requirement.
Risk Stratification
Identify high-risk patients using electronic data to target interventions. Participation in the programs listed above also meets this requirement.
Performance Measurement
Assess quality, cost of care, and use of Certified EHR Technology. MIPS-eligible practitioners can satisfy this through Value in Primary Care MVP.
Optimize Patient Care While Maintaining Compliance
The APCM model represents a significant shift in primary care management, offering a more flexible and comprehensive approach to reimbursement and care coordination. By understanding and implementing the key components and service elements of APCM, practices can optimize patient care while maintaining compliance with Medicare’s evolving policies.
