Blog

The Provider’s Guide to Advanced Primary Care Management

The purely fee-for-service healthcare model has resulted in fragmented, inefficient, and often reactive—rather than preventative—care. That’s why the Centers for Medicare and Medicaid Services (CMS) has introduced several value-based care programs to evolve healthcare toward a more effective, patient-centered approach. 

Advanced Primary Care Management (APCM) is a pivotal new program introduced to support primary care providers in shifting to value-based care, without entirely sacrificing fee-for-service reimbursements. APCM aims to realign care incentives around outcomes rather than service volume by reimbursing providers for preventive care services to risk-stratified Medicare patients. This approach has been proven to reduce healthcare costs, improve patient outcomes, and increase patient engagement.

We’ll take a closer look at the purpose, requirements, and common questions surrounding APCM so you can evaluate whether this program fits your practice and patient population. Particularly for those organizations already offering care management services, it’s critical to understand the nuances, similarities, and differences between this program and others. 

What is Advanced Primary Care Management?

Advanced Primary Care Management is a preventative care program for Medicare patients offered by providers who serve as the patients’ focal point of care. For providers, APCM provides a framework for focusing on quality and improving patient engagement. For patients, APCM aims to offer a more personalized care experience with coordinated care management across providers. The program is characterized by: 

• Longitudinal care: promotes team-based care and bundled services, reflecting the comprehensive nature of preventative primary care 
• Anytime access: includes patient access to the care team day and night, any day of the week 
• Primary care: positions primary care providers as the focal point of patient care, emphasizing the importance of early, team-based care interventions 
• Patient-centered approach: encourages patient engagement by prioritizing patient needs in program requirements

APCM shares many similarities with Chronic Care Management (CCM). Both programs require personalized care plans and aim to improve patient outcomes through proactive care coordination. Still, the programs have separate requirements. While your organization can offer both APCM and CCM, individual patients must be enrolled in either one program or the other at a given time.

APCM eligibility 

APCM requires the stratification of Medicare patients into three levels:

• Level 1: for patients with one or fewer chronic conditions
• Level 2: for patients with two or more chronic conditions
• Level 3: for patients with two or more chronic conditions who are also Qualified Medicare Beneficiaries

Each level has different reimbursement levels for the provider and coinsurance responsibilities for the patient. To determine who is a Qualified Medicare Beneficiary, practice staff can use the HIPAA Eligibility Transaction System (HETS) database. While Level 3 patients are a specific type of dual-eligible beneficiary, Level 1 and 2 APCM patients don’t have to be dual-eligible. They can be enrolled in Medicare only. 

You can see more details on each level in our guide to Advanced Primary Care Management. 

What does APCM include?

Advanced Primary Care Management programs integrate various services from existing care management and telehealth programs to provide comprehensive support tailored to individual patient needs. Below are the key components and programs included in APCM: 

• Chronic Care Management: Provides ongoing support for patients with chronic health conditions
• Transitional Care Management: Offers care coordination services to ensure safe and effective transitions between healthcare settings
• Principal Care Management: Focuses on helping patients manage a single high-risk disease
• Interprofessional Internet Consultation: Facilitates consultations among healthcare providers via the Internet
• Remote Evaluation of Patient Videos/Images: Allows providers to assess patient-submitted media for diagnostic and treatment purposes
• Virtual Check-In: Supports brief, patient-initiated interactions with a healthcare practitioner via various communication technologies.
• Online Digital E/M (e-Visit): Allows patient interactions with providers through online platforms

APCM combines features from Chronic Care Management, Transitional Care Management, and Principal Care Management with features like virtual check-in and electronic visits. However, it differs from other forms of care management because it needs to be offered by a provider who is the patient’s focal point of care, stratifies patients into levels based on need, and relies on quality measures to determine program success. 

Rather than focusing on specific time thresholds (e.g., 20 minutes for CCM), APCM emphasizes making service capabilities available to patients when they need them. The program can also be performed under general supervision, allowing care managers to offer APCM services with provider oversight. 

Advanced Primary Care Management requirements 

APCM must include multiple service elements to ensure comprehensive and patient-centered care:

1. Consent: Secure patient consent by asking if they want to enroll and record their consent.
2. Initiating visit: Require an initial visit for patients who haven’t seen their provider within the past three years.
3. 24/7/365 access to care: Provide a phone or text line for patients to ask health-related questions anytime. 
4. Continuity of care: Ensure patients can schedule successive appointments with the same care team to maintain continuity. 
5. Care in alternative ways: Offer services like home visits or expanded hours to accommodate different patient needs. 
6. Comprehensive care management: Conduct systematic assessments of medical and psychosocial needs and implement systems for preventative care and medication reconciliation.
7. Patient-centered care plan: Develop care plans collaboratively with patients, make them available electronically, and update them in a timely manner. 
8. Management of care transitions: Oversee transitions from hospitals, ERs, or skilled nursing facilities to patients’ homes and follow up with patients within seven days.
9. Community-based care coordination: Form relationships with other practitioners and home- and community-based services to assist patients.
10. Enhanced communication: Provide multiple patient communication methods, including secure messaging, email, online patient portals, and phone.
11. Population-level management: Stratify patients into three levels of APCM and identify appropriate, targeted interventions.
12. Performance measurement: Evaluate program effectiveness based on quality measures. MIPS-eligible providers must report for the Value in Primary Care MVP. 

Learn more about the significant updates from the 2025 Medicare Physician Fee Schedule Final Rule.

Advanced Primary Care Management (APCM) vs. Chronic Care Management (CCM)

While APCM and CCM are designed to improve quality and better support patients with care management needs, they have several practical differences. 

1. Chronic Care Management is billed according to the length of the care encounter, while Advanced Primary Care Management reimburses monthly based on services being available. 
2. Like Chronic Care Management, participating APCM patients gain access to a 24/7 care line and a dedicated care manager. However, APCM does not require monthly calls with a care provider. 
3. Advanced Primary Care Management includes the care transitions from one healthcare setting to another and related services; CCM does not.
4. For APCM, Medicare patients must be stratified into three distinct levels, while CCM does not stratify patients. 
5. Compared to CCM, APCM places more emphasis on quality and requires providers to participate in quality reporting and measurement.  

The differences between APCM and CCM are nuanced. If you have questions, it’s important to seek expert help. Finding a knowledgeable program provider can assist you in navigating the differences between the programs and determining which is best suited to your patient population and capacity. 

APCM vs. Transitional Care Management (TCM) 

Both APCM and Transitional Care Management (TCM) focus on patients with complex medical issues and care management. APCM, however, is broader in scope and purpose. You can think of TCM as a subset of APCM in terms of its goals and purpose. 

1. APCM coordinates primary care across multiple providers, while TCM focuses specifically on instances of care transition, such as moving from an inpatient hospital setting to a skilled nursing center or home. APCM is often billed as a bundled service, whereas TCM codes typically pertain to a specific instance of care unique to an individual patient’s care transitions. 
2. APCM focuses on delivering preventive care and includes access to alternative care delivery methods, such as home visits. However, a face-to-face visit is required for TCM, and the program narrowly addresses shifts from one care setting to another. 
3. TCM serves high-risk patients, including those recovering from significant surgeries or those with complex chronic conditions. On the other hand, APCM focuses on Medicare beneficiaries with varying degrees of complexity and chronic conditions. 

Although APCM is new, it is not intended to replace TCM or other value-based care programs. In fact, you can continue to offer CCM, Principal Care Management (PCM), TCM, and APCM. You just can’t enroll one patient in all of the programs at the same time. 

Your APCM program must include assistance during the transition from TCM to APCM to ensure continuity of care and minimize disruptions for the patient. This assistance should involve coordinating with the previous care team to obtain comprehensive patient history and current care plans, informing the patient of any changes in procedures or contacts, and closely monitoring the patient's health during the initial phase of the transition. 

Should your practice implement APCM or CCM? 

Implementing APCM or CCM depends on your organizational needs and factors like the type of patient you serve. If you haven’t adopted a care management program before, CCM might be an easier starting place. Compared to APCM, CCM has fewer requirements, and monthly reimbursement is based on time, rather than the availability of services. For practices familiar with care management, APCM might offer an alternative perspective that better suits your structure or patient needs. 

The approach to care management programs is not strictly 'either-or.' You can bill some patients under APCM and others under CCM, PCM, or TCM. Recognize, however, that running multiple different care programs simultaneously adds complexities and workload. Working with a partner who understands each value-based care program's requirements, goals, and distinct differences can make administering several programs more manageable. 

Learn more: How to Start a CCM Program: A Comprehensive Guide

How APCM impacts RHCs and FQHCs

Upcoming regulatory changes present significant changes for Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs), especially when it comes to how care coordination services are billed. Previously, these organizations could use the G0511 code for Chronic Care Management. Beginning July 2025, however, CMS will require them to adopt the CPT and HCPCS codes, such as 99490, that other providers already use for care coordination services.

This change may pose administrative and financial challenges for RHCs and FQHCs since the traditional codes are reimbursed at a lower rate than G0511. However, the switch will make it possible to bill additional units of care. 

Alternatively, RHCs and FQHCs can move to APCM. This model might be particularly beneficial depending on the patient demographics of an RHC or FQHC. For example, facilities with a larger number of Level 3 patients—who require the most complex care—may benefit from APCM's more robust offering and SDOH services as well as favorable reimbursement rates due to the enhanced care and coordination these patients demand.

Learn more: Rural Healthcare Challenges, Disparities, & Opportunities with Chronic Care Management 

Billing for APCM

APCM codes

The introduction of APCM will bring three new HCPCS codes: 

• G0556: APCM for Medicare patients with one or fewer chronic conditions (Level 1)
• G0557: APCM for Medicare patients with two or more chronic conditions (Level 2)
• G0558: APCM for Medicare patients with two or more chronic conditions who are Qualified Medicare Beneficiaries (Level 3)

If you wish to perform stratification yourself, your practice will need advanced reporting and population health capabilities. You can also partner with an experienced care management provider to help you stratify patients into appropriate levels. 

Reimbursement

Reimbursement varies by level. The national averages are:

• G0556: $15 per patient, per month
• G0557: $50 per patient, per month
• G0558: $110 per patient, per month

After a patient enrolls in the program, you can bill APCM monthly. APCM has no monthly time thresholds—providers and care managers are expected to adjust the amount of care provided based on the patient’s needs. All service elements must be available monthly, whether or not the patient uses them. 

APCM can be billed once per calendar month once the patient enrolls in the program. 

Patient coinsurance responsibility 

Medicare Part B and C will reimburse for APCM. Patients may have coinsurance payments, and deductibles apply. However, coinsurance amounts will vary by patient level. Patients with QMB status will not have an expected coinsurance. 

APCM and other care management programs

APCM, CCM, TCM, and PCM cannot be billed for the same patient in the same month. APCM contains many elements that overlap with Chronic Care Management, Transitional Care Management, and Primary Care Management. 

Advanced Primary Care services for all practices

Advanced Primary Care Management holds significant potential to enhance the health outcomes of Medicare patients. With the goal of reducing unnecessary hospitalizations and emergency room visits, APCM aims to improve patient quality of life and contribute to the overall efficiency of healthcare delivery. 

However, realizing these benefits requires robust patient stratification, comprehensive quality reporting capabilities, and a commitment to in-depth, personalized care management. Effectively implementing APCM demands a concerted effort to integrate these elements seamlessly, ensuring patients receive the proper care at the right time.

If you have questions about implementing an APCM or CCM program, our team at ChartSpan will gladly assist you. We’re experts in quality improvement and value-based care. We offer a full-service Chronic Care Management program to help your practice optimize health outcomes, enhance patient engagement, and maximize reimbursements. 

Contact us today to learn how our value-based care solutions can transform your practice and help you achieve your healthcare goals. 

You may also like:

• How to Choose the Right Chronic Care Management Vendor for Your Practice
• RHC and FQHC CCM: How Chronic Care Management Impacts At-Risk Patients