APCM vs. Traditional Chronic Care Management (CCM): Key Differences for Medicare Providers

Medicare offers multiple care management services to support patients with chronic conditions, with Advanced Primary Care Management Management (APCM) as one of the latest additions. While APCM and chronic care management (CCM) both enhance patient care and support continuity, APCM includes several key differences that may make it better suited for certain patient populations.

In this post, we’ll examine the differences between APCM and traditional CCM, highlighting coding, billing, and compliance requirements to help practices make informed decisions about implementing these services.

What is Chronic Care Management (CCM)?

Traditional chronic care management (CCM) was introduced by Medicare to improve support for patients with multiple chronic conditions. CCM services provide ongoing, non-face-to-face care coordination and require a minimum of 20 minutes of clinical staff time per patient, per month. CCM can be delivered by physicians or non-physician practitioners (NPPs) with general supervision of clinical staff.

Key features of CCM:

• For Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months or until death.
• Focuses on ongoing care coordination, medication management, and frequent patient check-ins.
• Minimum 20 minutes of care management time monthly to meet billing requirements for basic CCM.

What is Advanced Primary Care Management Management (APCM)?

APCM expands care management service options for patients with chronic conditions. Patients eligible for APCM generally may require equivalent or less hands-on care management support than their counterparts enrolled in CCM programs. Medicare’s APCM service is designed to address the current gap in compensating primary care providers (PCPs) for the comprehensive and continuous care they offer to their patients — regardless of the exact time spent furnishing the services each month.

Key features of APCM:

• All Medicare beneficiaries are eligible for APCM. The beneficiaries who are likely to benefit most from APCM are those with one or more chronic conditions.

• Allows providers to engage in multidisciplinary care coordination, involving physicians, nurses, social workers, and other healthcare professionals.
• Requires a detailed care plan and often includes remote patient monitoring (RPM) and other supportive services.

Coding Differences Between APCM and CCM

One of the most significant distinctions between APCM and CCM lies in the coding and reimbursement structure. Here’s a breakdown of the CPT codes commonly used for each service.

CCM Coding Overview

For CCM, Medicare offers several CPT codes depending on the complexity and time requirements of care management.

• CPT 99490: Basic CCM, used for at least 20 minutes of clinical staff time per calendar month under the general supervision of a physician or qualified healthcare professional. 
• CPT 99439: Add-on code for additional 20-minute increments of care management, which can be used twice per month, up to a total of 60 minutes.
• CPT 99491: Complex CCM, for at least 30 minutes of CCM provided by a physician or qualified healthcare professional, reimbursed at a higher rate.
• CPT 99487: For 60 minutes of complex CCM per month, typically involving moderate- to high-complexity medical decision-making. Reimbursement is higher to reflect the additional resources and expertise required.
• HCPCS G0511: Used by federally qualified health centers (FQHCs) and rural health centers (RHCs) for CCM, covering at least 20 minutes of care management.

APCM Coding Overview

Unlike for CCM, APCM codes not time-based. APCM follows its own set of requirements and reimbursement models. APCM coding uses three HCPCS codes:

• G0556: This code covers APCM services for a patient provided by clinical staff and directed by a physician or other qualified healthcare professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services for patients with one chronic condition or fewer, per calendar month. 
• G0557: This HCPCS code for APCM services is 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 G0556, as appropriate. 
• G0558: Finally, use this HCPCS code for APCM 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.  

Since APCM often includes RPM as a complementary service, integrating these codes with the main APCM codes allows for a more flexible billing structure. This helps practices capture more revenue while meeting the complex care needs of APCM patients.

Eligibility and Requirements for APCM vs. CCM

Both CCM and APCM are designed to support patients with chronic conditions, but there are key differences between the two services. CCM provides general support for patients with multiple chronic conditions, but APCM is more adaptable to a wider range of patient needs, including those with stable conditions and those requiring more complex management. Additionally, APCM offers more targeted billing codes, allowing providers to capture accurate reimbursement based on patient complexity.

CCM eligibility requirements:

• Patients must have two or more chronic conditions expected to persist for at least 12 months.
• These conditions should pose a risk of acute exacerbation, functional decline, or death.
• Patients must provide written or verbal consent, which must be documented in the medical record.

APCM eligibility requirements:

• Only primary care providers are eligible to bill for APCM services, as these providers are positioned to deliver holistic, longitudinal care to patients.
• All Medicare beneficiaries are eligible for APCM. 
• Patients must provide written or verbal consent, which must be document in the medical record.

Medicare Requirements and Compliance for APCM and CCM

Medicare’s documentation requirements for CCM are relatively straightforward, but APCM services require that 13 "service elements" must be "available" to patients each month to qualify for reimbursement. Each service element does not necessarily require practitioner action each month.

CCM compliance requirements:

• Comprehensive care plan: Each patient must have an up-to-date care plan, addressing their specific chronic conditions, medication management, and health goals.

• Time tracking: Time spent remotely interacting with patients, and on care management activities, must be logged and tracked.

• 24/7 patient access: CMS requires that CCM patients have 24/7 access to their care team, either by telephone or electronic communication.

APCM compliance requirements:

• Patient Consent: Inform the patient about the service, obtain consent, and document it in the medical record.

• Initiating visit: For new patients or those not seen within three years.

• Continuity of care: Ensure continuity with a designated team member for successive routine appointments.

• Alternative care delivery: Care delivery options alternative to office visits, such as home visits and/or expanded hours.

• Overall comprehensive care management: Conduct systematic needs assessments, ensure receipt of preventive services, manage medications and general clinical oversight.

• Patient-centered care plan: Develop and maintain a comprehensive electronic care plan accessible to the care team and patient.

• 24/7 access to care: Provide patients with 24/7 access to the care team/practitioner for urgent needs.

• Coordination of care transitions: Coordinate transitions between healthcare settings and providers, ensuring timely exchange of health information and follow-up communication. 

• Ongoing communication: Coordinate with various service providers and document communications about the patient’s needs, goals, and preferences.

• Enhanced communication opportunities: Enable communications through secure messaging, email, patient portals, and other digital means.

• Population data analysis: Identify care gaps and offer additional interventions as appropriate.

• Risk stratification: Use data to identify and target services to patients.

• Performance measurement: Assess quality of care, total cost of care, and use of certified EHR technology.

Which Service is Right for You: APCM, CCM, or Both?

The decision to offer APCM, CCM, or both should consider your patient population, staffing resources, and practice goals.

• CCM may be better suited for non-primary care practices managing a patient population with a high prevalence of chronic conditions. These patients may require frequent remote interaction over the phone that can be tracked under CCM's time tracking requirements.

• APCM is ideal for primary care practices managing patients with a spectrum of risk profiles. Some patients may need a relatively hands-off approach, while others may require more frequent touchpoints.

Partnering with Prevounce for APCM and CCM Success

Navigating the complexities of APCM and CCM coding, compliance, and documentation can be challenging. Prevounce offers an integrated platform to support both APCM and CCM services, ensuring your practice can deliver compliant, high-quality care while optimizing revenue.

Prevounce’s features for APCM and CCM include:

• Automated time tracking and billing: Effortlessly capture all time spent on care management to ensure full reimbursement.

• Care plan templates and compliance tools: Use comprehensive care plan templates for both APCM and CCM, ensuring Medicare compliance with every patient interaction.

• Integrated RPM options: Seamlessly incorporate remote patient monitoring services with APCM to deliver high-touch, data-driven patient care.

Learn More During Our APCM Crash Course

If your organization provides or is considering delivering remote care management services, you will want to learn about the new Advanced Primary Care Management (APCM) program. We'll dive into APCM in our upcoming 30-minute webinar, "Crash Course on Advanced Primary Care Management," on Jan. 9, 2025, 2:00 PM ET / 11:00 AM PT. Reserve your seat for this special event!

Capitalizing on the Benefits of APCM and CCM

APCM and CCM each bring unique benefits to Medicare providers, with APCM offering a more advanced care approach for patients with complex needs. By understanding the differences in coding, requirements, and compliance, providers can choose the right service to meet their patient population’s needs while enhancing practice revenue. For a streamlined, compliant approach to APCM and CCM, contact Prevounce today to see how our platform can support your care management goals.