At the end of November, CMS finalized the creation of three new HCPCS codes to come into effect in 2025,  to report advanced primary care management. The codes bundle several existing care management and communication technology-based services, in particular the codes for Chronic Care Management (CCM), Principal Care Management (PCP) and Transitional Care Management (TCM) care programs with one notable change: these codes can be billed for patients receiving a qualifying care service without the need to keep track of the time required to bill for it. Physicians may bill for APCM services monthly for beneficiaries for whom they are responsible for all primary care and serve as the continuing focal point for all needed health care services. 

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Although it might seem like a better alternative to the current and well established CPT codes covering CCM, PCM and TCM, given these new services do not require medical staff to track their time spent caring for enrolled patients, a closer look highlights several drawbacks with these new reimbursement codes. This blog post reviews the new codes in detail and weigh their pros and cons.

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What Advanced Primary Care Management (APCM) services cover?

These codes bundle several existing CPT codes into one monthly payment. These are the services and the relative existing codes:

Preventive care services:

• Principal care management (PCM) – disease-specific services to help manage a patient’s care for a single, complex chronic condition that puts them at risk of hospitalization, physical or cognitive decline, or death
• Transitional care management (TCM)
• Chronic care management (CCM)

Communication technology-based services include:

• Virtual check-ins
• Remote evaluations of pre-recorded patient information
• Interprofessional consultations

Who can bill for Advanced Primary Care Management (APCM) services?

From the language provided by CMS, these services are dedicated to primary care  providers and those who play a central role in their patients’ overall health strategy such as:

• Physicians or non-physician practitioners (NPP), including a nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS)
• You must be responsible for all of your patient’s primary care services
• You’re the focal point for all of your patient’s needed health care services
• You’ve gotten either written or verbal consent from your patient

How often can you bill for APCM services?

These codes can be billed once per month for each patient who received such a service, as long as you met the billing requirements to do so.

How do APCM reimbursements differ from the established codes?

Advanced primary care codes vary based on patient complexity and providers are required to choose the HCPCS code that’s the most appropriate for the patient’s medical and social complexity. These 3 APCM codes are:

G0556 for patients with a single chronic condition (comparable to PCM patients), paying $10 per month per patient

G0557 for patients with multiple chronic conditions (comparable to CCM patients), paying $50 per month per patient

G0558 for patients with multiple chronic conditions who is Qualified Medicare Beneficiary, paying $110 per month per patient

What are the billing requirements?

To bill for APCM services, you must complete these elements when they’re clinically appropriate for the individual patient:

• Get patient consent. Get written or verbal consent from the patient to participate in APCM services, and document it in the patient’s medical record. The consent must inform your patient that:some text
  • Only 1 provider can furnish and be paid for APCM services during a calendar month
  • They have the right to stop services at any time
  • Cost sharing may apply to the patient

  Get consent before you start APCM services. You only need to get consent once.

• Conduct an initiating visit (paid separately) for new patients. You don’t need to conduct this visit if you or another provider in your practice have:some text
  • Seen the patient within the past 3 years
  • Provided another care management service (APCM, CCM, or PCM) to the patient within the past year
• The Medicare Annual Wellness Visit (AWV) may qualify as the initiating visit if the provider that will be responsible for providing APCM care performs the AWV 
• Provide 24/7 access and continuity of care, including:some text
  • 24/7 access for your patients or their caregivers with urgent needs to contact you or another member of the care team
  • Real-time access to the patient's medical information
  • The ability for the patient to schedule successive routine appointments with a designated member of the care team
  • Care delivery in alternative ways to traditional office visits, like home visits or expanded hours  
• Provide comprehensive care management, including:some text
  • Systemic needs assessments (medical and psychosocial) 
  • System-based approaches to ensure receipt of preventive services 
  • Medication reconciliation, management, and oversight of self-management
• Develop, implement, revise, and maintain an electronic patient-centered comprehensive care plan.some text
  • The care plan must be available within and outside the billing practice, as appropriate, to individuals involved in the patient's care
  • Members of the care team must be able to routinely access and update the care plan
  • You must also give a copy of the care plan to the patient or caregiver
• Coordinate care transitions between and among health care providers and settings, including:some text
  • Referrals to other providers
  • Follow-up after an emergency department visit
  • Follow-up after discharge from a hospital, skilled nursing facility (SNF), or other health care facility 
• Coordination of care transitions must include: some text
  • Timely exchange of electronic health information with other health care providers
  • Timely follow-up communication (direct contact, phone, or electronic) with the patient or caregiver within 7 days of discharge from an emergency department visit, hospital, SNF, or other health care facility, as clinically indicated
• Coordinate practitioner, home-, and community-based care. You must provide ongoing coordinating communication and documentation on the patient’s psychosocial strengths, functional deficits, goals, preferences, and desired outcomes from practitioners, home- and community-based service providers, community-based social service providers, hospitals, SNFs, and others. 
• Provide enhanced communication opportunities. You must: some text
  • Offer asynchronous, non-face-to-face consultation methods other than the phone, like secure messaging, email, internet, or a patient portal
  • Be able to conduct remote evaluation of pre-recorded patient information and provide interprofessional phone, internet, or electronic health record (EHR) referral services
  • Be able to use patient-initiated digital communications that require a clinical decision, like virtual check-ins, digital online assessment and management, and evaluation and management (E/M) visits (or e-visits) 
• Conduct patient population-level management. You must:some text
  • Analyze patient population data to identify gaps in care 
  • Risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients 
• Measure and report performance, including assessment of primary care quality, total cost of care, and meaningful use of Certified EHR Technology (CEHRT). You can either:some text
  • Report the Value in Primary Care MIPS Value Pathway (MVP). You’ll report performance starting in 2026 for CY 2025. 
  • Participate in a Medicare Shared Savings Program Accountable Care Organization (ACO), Realizing Equity, Access, and Community Health (REACH) ACO, Making Care Primary model, or Primary Care First model.

Are providers able to bill both the established codes such as CCM, PCM or TCM while also billing for Advanced Primary Care Management codes?

No. APCM codes pay for the same services as CCM, PCM and all those other codes currently available to providers and billing both would be considered double-billing for the same service. 

Is Lara Health recommending their clients to switch to APCM codes?

Not at the moment. We have evaluated the attractiveness of these newly available codes for 2025 however, we do not feel there is enough information available to make such a recommendation, nor do we feel every client will be better off utilizing these new codes. Here is why:

• Although these codes remove the requirement to track clinical time required to qualify for reimbursements under APCM codes, the delivery of relevant services and documentation of those remains. 
• The average reimbursement for a patient enrolled into preventative programs and managed on the Lara Health platform far exceeds the monthly reimbursements the APCM codes offer (the average monthly reimbursement per patient in 2023 was $107 vs $50 for APCM)
• APCM codes mandate practices to forgo not just CCM and PCM codes, but they also eliminate payments for Transitional Care Management services, virtual check-in, interprofessional consultations and more, likely resulting in much lower payments practices see today.
• Although APCM codes can be billed together with remote patient monitoring and remote therapeutic monitoring codes, the fact that APCM bundles most of the care that can also be captured under RPM and RTM means achieving reimbursements for RPM and RTM will be that much harder.
• It is unclear if practices will be able to apply these new codes to patient care under 20 minutes while applying the existing one (such as the existing CCM codes 99490 and 99438) to the rest of the patients, effectively allowing to ”mix and match” both new and old codes to maximize monthly reimbursements. Our expectation is that CMS will require practices to either stay with the existing codes or switch their whole eligible patient population to the new codes. This poses a further question whether practices will be able to switch back if this move proves less profitable over time.
• CMS is putting strong emphasis on tying these new codes to proactive population-level management, as well as analyzing and reporting care quality and total cost of care as part of the service. It is unclear if not meeting expected metrics would jeopardise future payments to providers or if such payments could be clawed back.

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With these newly announced reimbursements for 2025, there should be no doubt the CMS is strongly encouraging physicians to focus their efforts on preventative care supported by technology. The 3% pay cut to office based visits is another warning sign to physicians that CMS is determined to push value based care and preventative care methods by simultaneously offering financial incentives to those who implement them while financially disadvantaging those providers who don’t.

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Lara Health all-in-one platform allows medical practices to implement technologies that streamline and simplify implementation and management of such care models.