Advanced Primary Care Management (APCM)

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The Department of Health and Human Services is initiating measures to bolster primary care, beginning with payments for advanced primary care management services. Consequently, the Centers for Medicare and Medicaid Services (CMS) are proposing new regulations for Advanced Primary Care Management (APCM) services in the 2025 Medicare Physician Fee Schedule (PFS).

The primary areas of focus for these new ACPM codes include:

  • (3) HCPCS codes proposed are categorized by the number of chronic conditions.
  • New codes also facilitate longitudinal care (as described in other care management codes).
  • ACPM providers act as a consistent focal point for all necessary healthcare services.

Similar to other care management services, obtaining informed consent and its documentation in the medical record is required. As is 24/7 access to care and continuity. The Nixon Gwilt Law article provides an accessible overview, offering a clear summary of the proposed rule, clinical expectations, and a highly useful code description table. It’s worth taking the time to understand what these proposed codes involve. However, if you want to dive into the proposed rule yourself, the necessary criteria for reporting APCM are detailed on page 278 of the Federal Register. We will closely monitor this proposal and provide a follow-up once the final rule is established in November.

Payment

APCM services are compensable to physicians or qualified healthcare professionals overseeing a patient’s primary care for the duration of a calendar month.

Codes

Three G-codes will be used to represent different payment levels for APCM services. The new proposed codes are G0556, G0557, and G0558.

G0556 – G0558 describe APCM services furnished per calendar month by the practitioner assuming the care management role for a beneficiary.

  • G0556: Advanced primary care management services provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month. Proposed valuation: $15/month (RVU of 0.17)

  • G0557: Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the elements included in GPCM1, as appropriate. Proposed valuation: $50/month (RVU of 0.77)

  • G0558: Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the elements included in G0556, as appropriate. Proposed valuation: $110/month (RVU of 1.67)

Payment levels

Payment levels correspond to the patient’s clinical complexity and their income or resource level. For instance, G0556 applies to patients with no more than one chronic condition, whereas G0557 is designated for patients with multiple chronic conditions.

Services

APCM services encompass a comprehensive bundle of care management and communication technology-based services, including chronic care management, transitional care management, and principal care management.

Performance measurement

APCM services must be reported through the Value in Primary Care MVP.

Conclusion

In conclusion, CMS says the proposed coding and payment system aims to more accurately represent and detail advanced primary care services. This proposal would promote the transformation of primary care practices, contribute to the provision of high-quality primary care services for patients, and streamline billing and documentation processes when compared to current care management and communication technology-based service codes.

Resources

UT Health (Internal link) APCM Chart

2025 MPFS Proposed Rule Fact Sheet

Federal Register:  2025 MPFS Proposed Rule (see pg. 276)

Strengthening Primary Care – HHS.gov article

National Academies – Implementing High Quality Primary Care

HFMA – APCM Article

Nixon Gwilt Law Article

McDonald Hopkins – Legal Update Article