Advanced Primary Care Management
Launch and run Medicare APCM with your existing team
Advanced Primary Care Management (APCM) is Medicare's monthly, per-patient bundled payment for primary care practices that serve as a patient's continuing focal point for care. Unlike Chronic Care Management, it has no minimum-minutes requirement: payment depends on patient complexity and on the practice's ability to deliver 13 defined service elements.
- HCPCS G0556 · G0557 · G0558
- Billable since January 1, 2025
- No monthly time threshold
Who it's for
Built for the organizations that carry this work
APCM pays for being the patient's accountable primary care home, not for counting minutes. It fits organizations of every size that bill Medicare Part B for primary care.
Independent and small practices
A practice that could never sustain CCM enrollment usually can sustain APCM, because there is no monthly minute threshold to meet before a claim can go out.
Practices already billing CCM
APCM is a patient-by-patient decision, not a replacement: Level 1 patients who were never CCM-eligible, months that fall below the 20-minute CCM threshold, and Qualified Medicare Beneficiaries with two or more chronic conditions.
FQHCs and RHCs
Billable since 2025 as a stand-alone monthly payment outside the encounter rate. It does not replace or reduce the PPS or AIR payment for visits you already bill.
Medical groups and IPAs
One enrollment and documentation standard for every location, roles assigned per site, a site-level scorecard, and one billing practitioner per patient per month.
ACOs and networks
MSSP or ACO REACH participation meets APCM's performance-measurement requirement, and the monthly touch supports the measures the ACO is scored on.
What we do
What you receive
We design, launch and operate the program inside the EHR you already use. No new platform, no data migration.
- 01
Readiness report and panel analysis
Panel mapping, a 12-month CCM claims analysis and a gap review against the 13 service elements, with your quality-reporting route confirmed.
- 02
Program design
Level-assignment logic, CCM-versus-APCM sorting rules, staffing model, 24/7 access option and reporting plan, documented in a program design document and staffing plan.
- 03
EHR build, SOPs and training
Templates and care plan in your EHR, consent workflow, billing workflow with concurrency checks, risk stratification and patient materials.
- 04
Payer verification
Before launch, we confirm APCM coverage, allowed amounts and member cost-sharing with each Medicare Advantage plan you contract with.
- 05
Pilot and go / no-go
One provider panel first, with documentation and claims QA, consent-rate tracking and a pilot scorecard.
- 06
Ongoing operations and audit readiness
Roll-out to all providers, then monthly oversight of enrollment, level assignment, claims QA and KPIs (or day-to-day program operations with your staff), with quarterly chart audits against the 13-element checklist.
How it works
How an engagement runs
From assessment to full roll-out in about four months.
- 1Weeks 1–2
Readiness
Panel and CCM claims analysis, 13-element gap review, reporting route confirmed. You receive the readiness report and revenue model.
- 2Weeks 3–5
Design
Sorting rules, staffing, 24/7 access option and reporting plan, captured in a program design document.
- 3Weeks 6–9
Build
EHR templates, consent workflow, billing checks and patient materials, with SOPs and staff training.
- 4Weeks 10–17
Pilot
One provider panel, documentation and claims QA, then a go / no-go decision.
- 5Month 5 on
Scale
All providers, KPI dashboard, quarterly audits and behavioral health add-ons where they apply.
Typical sequence from our APCM program guide. Timing depends on EHR access, staffing and the reporting route.
Program facts
Codes, requirements and rules
Program rules for Medicare fee-for-service, as published by CMS.
Three levels, set by two facts only
The level is determined by chronic condition count and Qualified Medicare Beneficiary (QMB) status. Time spent and monthly intensity do not change it.
Level 1
- HCPCS
- G0556
- Patient criteria
- 0–1 chronic conditions
- CY 2026 national rate
- $16.37
Level 2
- HCPCS
- G0557
- Patient criteria
- 2+ chronic conditions expected to last 12+ months (or until death) that place the patient at significant risk
- CY 2026 national rate
- $53.78
Level 3
- HCPCS
- G0558
- Patient criteria
- Meets Level 2 criteria and is a Qualified Medicare Beneficiary
- CY 2026 national rate
- $117.24
Illustrative only: CY 2026 Medicare Physician Fee Schedule national non-facility amounts. New York's five Medicare payment localities adjust these rates; check your locality in the CMS PFS Look-Up Tool. Billed once per patient per calendar month.
The 13 service elements
The practice must be capable of delivering every element, and document it. Not every element is delivered to every patient every month.
Access
- Consent
- Initiating visit
- 24/7 access
- Continuity of care
- Alternative care delivery
Care management
- Comprehensive care management
- Patient-centered care plan
- Care transitions
- Ongoing coordination
- Enhanced communication
Population health
- Population data analysis
- Risk stratification
Accountability
- Performance measurement
What can be billed in the same month
The restriction applies to the same practitioner, the same patient and the same calendar month.
CCM, PCM, TCM
- Can bill alongside APCM
- Remote Physiologic Monitoring (RPM)
Virtual check-ins; remote evaluation of images or video
- Can bill alongside APCM
- Community Health Integration (CHI)
Interprofessional internet consultation
- Can bill alongside APCM
- Principal Illness Navigation (PIN)
Online digital E/M (e-visits)
- Can bill alongside APCM
- Behavioral health add-ons G0568, G0569, G0570 (CY 2026)
Services billed concurrently must not count the same time or effort twice and must independently meet their own requirements.
The performance-measurement requirement
The billing practitioner reports the Value in Primary Care MIPS Value Pathway (MVP), or participates in an MSSP ACO or ACO REACH. Traditional MIPS reporting does not satisfy the requirement.
MSSP / ACO participant
- How the requirement is met
- ACO participation
- Work involved
- Confirm every APCM billing NPI is on the ACO participant list; align the care plan and risk stratification with ACO quality measures.
ACO REACH or other APM
- How the requirement is met
- REACH participation; confirm any other model qualifies for the performance year
- Work involved
- Review how APCM billing interacts with model payments; verify qualifying status each year.
MIPS only
- How the requirement is met
- Report the Value in Primary Care MVP
- Work involved
- MVP readiness, measure selection and EHR reporting build. Multispecialty practices with more than 16 eligible clinicians report as a subgroup or as individuals.
Three ways to meet the 24/7 access requirement
Every option must route urgent needs to a member of the care team with real-time access to the patient's medical record. An answering service alone does not meet the requirement.
Provider on-call rotation
Strong
Low cash cost, high burnout risk. Works best for groups of four or more providers with remote EHR access.
Nurse triage service
Strong with EHR access
Per-call or per-member fee. Confirm record access and the path for documentation back to your chart.
Answering service + escalation
Adequate with a written SOP
Lowest cost. Needs a documented escalation protocol and a call log retained for audit.
Who pays for APCM in New York
Medicare fee-for-service is the only payer confirmed to pay APCM. Medicare Advantage plans must cover Original Medicare Part B benefits, but whether and how they pay APCM follows each contract.
Medicare fee-for-service (Part B), via National Government Services
- Status
- Billable
- Notes
- Physician Fee Schedule rates by New York locality; 20% coinsurance unless QMB or supplemental coverage.
Medicare FFS: FQHC / RHC
- Status
- Billable
- Notes
- Paid at the national non-facility PFS rate when billed on an FQHC or RHC claim.
Medicare Advantage (HMO / PPO / PFFS)
- Status
- Verify contract
- Notes
- G-code acceptance, rate, cost-sharing and authorization follow your contract. Some plans run their own care management.
D-SNP and Medicaid Advantage Plus
- Status
- Verify contract
- Notes
- Medicare side pays per contract. G0558 still requires QMB status.
Medicare secondary coverage (Medigap, retiree plans, TRICARE For Life, NY Medicaid for QMB / duals)
- Status
- Secondary
- Notes
- Bill Medicare first; the secondary covers the coinsurance. QMB patients owe nothing.
NY Medicaid FFS and Medicaid Managed Care, HARP, HIV-SNP
- Status
- Not payable
- Notes
- Not on the NY Medicaid fee schedule; NYS PCMH payments apply instead.
PACE
- Status
- Not payable
- Notes
- Capitated; care management is included in the PACE payment.
Commercial, Child Health Plus, Essential Plan
- Status
- Not payable
- Notes
- No published APCM policy; G0556–G0558 are Medicare-defined codes.
Status as of September 2026, from a public-policy search. Re-verify each payer contract before billing and recheck annually.
FAQs
Common questions
What does the patient pay?
Standard Part B coinsurance and deductible for most patients; nothing for Qualified Medicare Beneficiaries; supplemental plans frequently cover it. The consent conversation covers this once, and the patient can stop at any time.
How much staff time does APCM take?
There is no minimum. What the program requires is that the service elements are available and documented. As a planning benchmark, one care manager FTE supports about 400 enrolled patients; the figure is validated during the pilot against your level mix.
Do we need new software?
No. The program is built inside the EHR you already use: no new platform, no data migration, nothing your staff logs into twice.
What happens to our existing CCM patients?
For an enrolled patient, APCM replaces CCM, PCM and TCM in that month by the same practitioner; a patient is on one or the other. Patients who consistently receive 40 or more minutes a month should be modeled both ways, because CCM add-on codes can exceed the Level 2 rate. Exceptions are decided patient by patient, and switching patients need a new APCM consent.
What is the quality-reporting requirement?
Practices report through the Value in Primary Care MIPS Value Pathway, or meet it through ACO participation (MSSP or REACH). Traditional MIPS does not count. The route is confirmed in the first two weeks.
Do I have to offer 24/7 access myself?
You have to make sure a patient can reach a member of the care team with real-time access to their record for urgent needs. A provider on-call rotation, a nurse triage service with EHR access, or an answering service with a written escalation protocol can each work; an answering service alone does not.
Can FQHCs and RHCs bill APCM?
Yes, since 2025. The APCM codes are billed as a stand-alone monthly payment outside the encounter rate, so the PPS or AIR payment for the visits you already bill is not reduced. Your billing team should be involved early so the claim setup is right from the first cycle.
I am a specialist who is effectively the patient's main doctor. Can I bill it?
If your practice is the patient's continuing focal point for all of their care, yes. Only one practitioner can bill APCM for a patient in a given month.
What happens if we are audited?
APCM removes the time-log exposure CCM carried. What has to be defensible is consent, the level and its basis, the care plan and the availability of the service elements, which is what a monthly pre-claim review and a quarterly chart audit check.
What if a patient opts out after a few months?
They can stop at any time, effective at the end of that calendar month; you simply stop billing the code. The care plan and the relationship stay.
Ready to simplify the complex?
Let’s look at your program together.
A consultation is a working conversation about your panel, payers and EHR, and whether this service fits. Please do not send patient information.
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