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The Provider’s Guide to Advanced Primary Care Management

The purely fee-for-service healthcare model has led to fragmented, inefficient, and often reactive—rather than preventative—care. To advance a more effective, patient-centered approach, the Centers for Medicare and Medicaid Services (CMS) has introduced several value-based care programs.

Advanced Primary Care Management (APCM) is the newest of these programs, designed to support primary care providers as they transition to value-based care while still benefiting from fee-for-service reimbursements. By reimbursing providers for offering preventive care services to risk-stratified Medicare patients, APCM aims to realign care incentives around outcomes rather than service volume. This approach has been proven to reduce healthcare costs, improve patient outcomes, and increase patient engagement.

Determining whether APCM is the right fit for your practice starts with understanding how it works and how it differs from other care management programs. While APCM shares common goals with CCM and TCM, its structure, flexibility, and focus on prevention offer distinct advantages for providers caring for Medicare patients.

Table of contents:

Chapter 1: What is APCM?
Chapter 2: Benefits of APCM
Chapter 3: APCM vs. CCM and TCM
Chapter 4: Implementing APCM
Chapter 5: APCM billing and reimbursement
Chapter 6: ChartSpan’s APCM services

APCM at a glance:

APCM supports centralized, proactive primary care to reduce hospitalizations and improve outcomes.
Medicare patients are assigned to one of three levels, with greater care needs corresponding to higher reimbursements for practices.
Practices can bill APCM services if they offer the required elements—even if they’re not all provided that month.
Success is measured by outcomes, and MIPS-eligible providers must participate in quality reporting.
The same practice can offer APCM, CCM and TCM, as long as they ensure a single patient isn’t enrolled in both APCM and CCM or APCM and TCM. This offers flexibility for practices already delivering care management.

Chapter 1:

What is Advanced Primary Care Management (APCM)?

Advanced Primary Care Management (APCM) is a flexible, preventative care program that offers continuous support for all Medicare patients between visits and across healthcare settings. Led by the patient’s focal point of care, usually their primary care provider, APCM helps practices shift toward value-based care by enabling prevention, early intervention, and improved patient engagement.

Instead of focusing on time-based thresholds, APCM reimburses providers for the availability of comprehensive services, encouraging practices to deliver ongoing, tailored care that improves outcomes and reduces costs tied to avoidable ER visits or preventable complications.

The program is excellent for addressing principles and values like:

Longitudinal care: A bundled, team-based approach to primary care delivery
Anytime access: 24/7 care team availability for urgent needs or patient questions
Primary care leadership: Coordination managed by a central primary care provider
Patient-centered support: Personalized care aligned with each patient’s needs and circumstances

APCM is a flexible care model, meaning the services provided each month vary based on each patient’s individual needs. For example, if a patient is discharged from the hospital one month, their provider must coordinate transitional care for 30 days following their discharge. However, that level of support won’t be required the next month unless the patient is hospitalized and discharged again.

What does APCM include?

APCM offers patients more personalized care and better coordination between providers. Between visits, patients receive support for care transitions, chronic condition management, medication refills, appointment scheduling, and social needs such as transportation or food access.

To provide this level of care, APCM combines elements of several existing programs:

Chronic Care Management (CCM): Ongoing support for patients with chronic conditions
Transitional Care Management (TCM): Safe, coordinated transitions between healthcare settings
Principal Care Management (PCM): Focused support for a single high-risk disease
Interprofessional Internet Consultations: Digital collaboration among providers
Remote Evaluation of Patient Videos/Images: Assessment of patient-submitted media
Virtual Check-In: Brief, patient-initiated interactions via phone or other technologies
Online Digital E/M (e-Visit): Secure, asynchronous communication with providers

Unlike other programs, APCM integrates select features of these services into a single, adaptable model led by a primary care provider or focal point of care. Patients are stratified into three levels based on clinical complexity and socioeconomic need. Program success is measured not by time, but by quality, aligning reimbursements with preventive care service availability.

Who is eligible for APCM?

APCM extends preventative care access to all Medicare patients, but participation requires patient stratification into one of three levels based on the number of chronic conditions and whether the patient is a Qualified Medicare Beneficiary (QMB):

Level	Stratification criteria	HCPCS code	Reimbursement*
Level 1	Patients with one or fewer chronic conditions	G0556	$15 per patient, per month
Level 2	Patients with two or more chronic conditions	G0557	$50 per patient, per month
Level 3	Patients with two or more chronic conditions and Qualified Medicare Beneficiary status	G0558	$110 per patient, per month

*Reimbursement rates are based on national averages and will vary depending on your practice's location.

Medicare Part B and C reimburse for APCM services. Patients may be responsible for coinsurance and deductibles, though these amounts vary by level. Notably, patients with QMB status (Level 3) do not pay coinsurance.

To confirm QMB eligibility, practice staff can use the HIPAA Eligibility Transaction System (HETS) database. While Level 3 patients must be dual-eligible for Medicare and Medicaid, Level 1 and 2 patients can be eligible for Medicare only.

Provider requirements for APCM

As the program title implies, Advanced Primary Care Management must be billed by a patient’s focal point of care, usually their primary care provider. But what is actually required of your practice before you can bill for APCM? Here is what you need to know:

APCM service element requirements

To ensure comprehensive, patient-centered care, APCM requires practices to offer each of these 10 service elements:

Consent: Secure patient consent by asking if they want to enroll, and record their consent in the patient’s medical record.
Initiating visit: Conduct an initial visit for patients who haven’t seen their provider within the past three years.
24/7 access and continuity of care: Provide a phone or text line for patients to ask health-related questions anytime, and ensure patients can schedule successive appointments with the same care team to maintain continuity.
Comprehensive care management: Conduct systematic assessments of medical and psychosocial needs, implement systems for preventative care, and oversee medication reconciliation and management.
Patient-centered care plan: Collaborate with patients to develop and implement personalized care plans, making them available electronically and updating them routinely.
Coordination of care transitions: Oversee transitions from hospitals, ERs, or skilled nursing facilities to patients’ homes, exchange electronic health information with other providers, and follow up with patients within seven days.
Community-based care coordination: Form relationships with other practitioners and home- and community-based services, and document the patient’s psychosocial strengths, functional deficits, goals, preferences, and desired outcomes.
Enhanced communication: Provide multiple patient communication methods, including secure messaging, email, online patient portals, and phone.
Population-level management: Identify gaps in care based on patient population data, and stratify the practice population into three levels to target appropriate services to patients.
Performance measurement: Evaluate program effectiveness based on quality measures. MIPS-eligible providers must report for the Value in Primary Care MIPS Value Pathway (MVP), unless you are enrolled in an Accountable Care Organization (ACO).

Supervision and oversight

Just like CCM, APCM requires general supervision: the provider must oversee and coordinate the program but does not need to be present when services are performed. Non-physician practitioners and care managers can bill for APCM services “incident to” the patient’s provider at the same practice.

Chapter 2:

Benefits of Advanced Primary Care Management

APCM is designed to improve care delivery for patients while supporting providers in their transition to value-based care. By focusing practice goals on quality outcomes and offering a more structured approach to patient engagement, APCM benefits both patients and providers, making it easier for providers to deliver personalized support while implementing sustainable processes for primary care practices.

APCM benefits for patients

24/7 access to a care team

A 24/7 care line gives patients around-the-clock access to a team who can answer questions, escalate concerns, or provide guidance, reducing unnecessary emergency room visits and helping patients feel supported between appointments.

Personalized care plan

Patients receive tailored care plans based on their individual health needs, chronic conditions, and social factors. This patient-centered approach leads to more relevant, effective care that evolves with their needs.

Coordinated transitions

APCM ensures that patients experience smooth transitions across healthcare settings. Whether individuals have been discharged from the hospital or referred to a specialist, care team members help coordinate their next steps and maintain continuity of care. Patients discharged from an inpatient setting also receive dedicated follow-up for 30 days.

Management of chronic conditions

Patients with chronic conditions receive proactive care through regular check-ins, monitoring, and follow-up care, making it easier for them to stay on top of complex health needs and avoid complications.

Medication management

Care teams help patients manage prescriptions by checking on which medications a patient is prescribed, coordinating refills, monitoring side effects, and ensuring medication adherence—all processes that reduce patients’ risk of worsening health conditions and improve outcomes.

APCM benefits for practices

Reduced time tracking

APCM eliminates the time-based documentation requirements of CCM. Instead of tracking time thresholds, practices bill based on availability of services—a shift that places more emphasis on patient needs and personalization.

Better patient engagement

With continuous access to a care team, frequent touchpoints, and educational resources, APCM encourages deeper patient involvement in healthcare. This leads to stronger relationships with their provider, more realistic care goals, and better goal adherence, which are key drivers of improved health outcomes.

Improved quality performance

APCM encourages a value-based care model, which focuses on personalized, preventive care and measuring success by outcomes rather than volume. This can support performance across other CMS programs and quality initiatives.

Patient-centered care

Because services are tailored to each patient’s unique needs and goals, practices can deliver more proactive, comprehensive care by addressing chronic conditions, care transitions, and social determinants of health (SDOH) to improve patient satisfaction and outcomes.

Recurring revenue stream

Monthly reimbursements based on patient stratification provide consistent revenue*, helping practices invest in staff, technology, and patient services. For those serving high proportions of Medicare patients, these predictable reimbursements support long-term sustainability.

*Results may vary by provider.

Chapter 3:

APCM vs. Chronic Care Management (CCM)

While APCM and Chronic Care Management (CCM) both aim to improve patient outcomes through ongoing support and care coordination, they differ in structure, scope, and billing.

Both programs focus on proactive, personalized care for Medicare patients with chronic conditions. They require individualized care plans, emphasize continuous engagement, and offer patients access to a 24/7 care team and a dedicated care manager. However, beyond these shared goals, the programs diverge in several practical ways.

Key differences:

Eligibility: APCM stratifies Medicare patients into three levels based on complexity and socioeconomic need. CCM does not use stratification.
Billing model: CCM is billed each month that 20+ minutes of care coordination is spent on a patient. By contrast, APCM reimburses a fixed monthly amount based on availability of services, not time thresholds.
Care requirements: Unlike CCM, APCM does not require monthly calls with a care manager. The care manager can determine an appropriate cadence of outreach, depending on the patient’s needs.
Transitional care: APCM includes care transitions when patients move between healthcare settings. CCM does not.
Quality focus: By requiring participation in quality measurement and reporting, APCM places greater emphasis on quality improvement than CCM.

While practices can offer both APCM and CCM, each patient can only be enrolled in one program at a time. For guidance on which care model best fits your practice and patient population, it’s helpful to consult with a knowledgeable program partner.

Learn about transitioning from CCM in our guide to Advanced Primary Care Management.

APCM vs. Transitional Care Management (TCM)

While both APCM and Transitional Care Management (TCM) support patients during care transitions, APCM takes a broader, more longitudinal approach to care.

Key differences:

Scope and purpose: TCM is designed to support patients as they move between healthcare settings, such as from a hospital to home or a skilled nursing facility. It focuses specifically on the 30 days following discharge, while APCM encompasses ongoing preventive care and care coordination across providers, including—but not limited to—care transitions.
Billing structure: TCM is billed for a single service tied to a recent hospital discharge and requires a face-to-face visit within a specific timeframe. APCM is billed monthly based on the availability of comprehensive primary care services. While a face-to-face visit should be scheduled after a discharge, APCM does not require it for billing.
Patient eligibility: TCM typically serves high-risk patients recovering from serious illness or surgery. APCM includes a wider range of Medicare beneficiaries with varying degrees of complexity and chronic conditions.

APCM is not intended to replace TCM or other value-based care programs. In fact, you can continue to offer CCM, TCM, and APCM. However, you can’t enroll the same patient in APCM and CCM or APCM and TCM.

Should your practice implement APCM or CCM?

Deciding between Advanced Primary Care Management and Chronic Care Management depends on your organization’s structure, resources, and patient population.

If your practice is new to care management, CCM may be an easier place to start. It has fewer program requirements than APCM, and reimbursement is based on the time spent delivering care, rather than on the availability of comprehensive services. CCM is often a good fit for organizations serving patients with multiple chronic conditions who need regular but relatively straightforward support.

Explore ChartSpan’s Chronic Care Management program →

For practices already experienced with care management, or those looking to adopt a more flexible, patient-centered approach, APCM may be a better fit. It supports more complex care coordination, enables continuous support for patients with a wide range of health and social needs, and reimburses extra for care provided to patients with high socioeconomic and medical needs.

But this is not necessarily an “either-or” decision. You can bill some patients under APCM and others under CCM, PCM, or TCM, depending on individual needs and eligibility. However, administering multiple programs simultaneously introduces complexity and added administrative workload.

Partnering with a care management provider who understands each model’s requirements and distinctions can help streamline operations and reduce burden on staff.

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

APCM as a G0511 alternative for RHCs and FQHCs

Billing changes are reshaping care coordination for Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs). As of October 1, 2025, these organizations will no longer be able to use the G0511 code for any of their care management programs. Instead, they’ll be required to adopt each program’s individual CPT and HCPCS codes that are already in use by other providers.

This shift presents both administrative and financial challenges. Unlike G0511, which allowed for a single, standardized payment, the alternative codes often reimburse at lower rates and require more detailed billing and documentation. While the change enables billing for multiple units of care management services, it also increases complexity.

For many RHCs and FQHCs, APCM may offer a more strategic and sustainable path forward. These practices often serve a high percentage of Level 3 patients, who require the most complex care. Under APCM, caring for these patients may give practices higher monthly reimbursements than what was offered under G0511. In addition, APCM supports a broader scope of services, including population health interventions, that improve patient engagement and outcomes among safety-net providers.

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

Chapter 4:

Implementing APCM services

Advanced Primary Care Management can help practices deliver more coordinated, proactive care while generating consistent revenue* through fee-for-service reimbursements and value-based quality payments. But to successfully launch and sustain an APCM program, you need the right systems, staff, and workflows in place.

Below are the resources your practice needs to support APCM. We’ll also walk you through the key steps for implementation—whether you're building an internal team or partnering with a care management provider like ChartSpan.

*Results may vary by provider.

Resources needed

Thinking about launching APCM at your practice? Start by ensuring you have the core tools, staff, and systems in place to support care delivery and reporting.

Eligibility and patient status data: Access to the HIPAA Eligibility Transaction System (HETS) to verify Medicare enrollment and Qualified Medicare Beneficiary (QMB) status.
Hospital discharge notifications: A system for receiving real-time alerts when patients are discharged from hospitals or other inpatient facilities, enabling timely transitional care.
Population health tools: Platforms that combine clinical data from multiple sources to monitor care outcomes and identify care gaps across the population.
Staff to support 24/7 access and care coordination: A dedicated team that can manage an around-the-clock care line, respond to urgent patient needs, and conduct regular outreach to review care goals, update care plans, and ensure continuity between visits.
Referral networks: Strong connections to community-based and home care organizations and SDOH resources, such as food assistance, housing, or transportation support.
Medication management support: Systems for medication reconciliation and coordination to reduce errors, improve adherence, and ensure patients are taking the right medications.
Analytics and reporting tools: Ongoing population health analytics to track quality measures, guide program improvement, and ensure compliance with APCM requirements.

How to implement APCM step-by-step

A well-implemented APCM program can add value for patients and generate additional revenue* for your practice. Below are the steps to launching an effective program—and how a care management partner, like ChartSpan, can ease the lift.

*Results may vary by provider.