CMS Guidelines for APCM Services: A Complete Guide to APCM Codes

Advanced Primary Care Management Management (APCM) is a Medicare service designed to support primary care providers (PCPs) in delivering continuous, patient-centered care to Medicare beneficiaries with varying levels of healthcare needs. Under guidelines from the Centers for Medicare & Medicaid Services (CMS), only primary care providers — such as family medicine, internal medicine, and geriatrics practitioners — as well as federally qualified health centers (FQHCs) and rural health clinics (RHCs) can furnish APCM services, as the program is aimed at managing the holistic health needs of patients across the complexity spectrum.

Understanding these CMS requirements is crucial to ensure compliance, deliver high-quality care, and capture appropriate and complete reimbursement. In this guide, we cover CMS guidelines for APCM, from APCM codes and patient eligibility to documentation and billing, so your primary care practice can implement an effective, compliant APCM program.

Eligibility Requirements for APCM Patients

APCM is available to all Medicare beneficiaries, including those with or without chronic conditions. The service supports patients with a range of health complexities. APCM is specifically designed for primary care providers, and it is eligible for patients with both stable and complex health needs.

APCM eligibility criteria:

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

To efficiently identify eligible patients, primary care providers may benefit from EHR or care management software to automate patient selection based on CMS’s criteria.

Billing and Coding Guidelines for APCM

CMS has established specific billing codes for APCM that reflect the time and complexity of care provided by primary care providers. Accurate use of these three HCPCS codes is essential for proper reimbursement.

APCM billing codes:

• Level 1 — HCPCS G0556 — is for patients with one chronic condition or fewer.
  • $10 per patient per month proposed reimbursement
• Level 2 — HCPCS G0557 — is for those with two or more chronic conditions.
  • $50 per patient per month proposed reimbursement
    
• Level 3 — HCPCS G0558 — is for patients with multiple chronic conditions who are also Qualified Medicare Beneficiaries.
  • $110 per patient per month proposed reimbursement
    

APCM service elements:

13 total "service elements" must be available to patients in order to bill for G0556, G0557, and/or G0558 each month. CMS notes "available" because not all service elements necessarily include monthly action on behalf of the practitioner or clinical staff.

1. Patient Consent

Inform the patient about the service, obtain consent, and document it in the medical record.

2. Initiating visit

For new patients or those not seen within three years. 

3. Continuity of care  

Ensure continuity with a designated team member for successive routine appointments. 

4. Alternative care delivery 

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

5. Overall comprehensive care management 

Conduct systematic needs assessments, ensure receipt of preventive services, manage medications and general clinical oversight. 

6. Patient-centered care plan 

Develop and maintain a comprehensive electronic care plan accessible to the care team and patient. 

7. 24/7 access to care 

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

8. Coordination of care transitions 

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

9. Ongoing communication 

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

10. Enhanced communication opportunities 

Enable communications through secure messaging, email, patient portals, and other digital means. 

11. Population data analysis 

Identify care gaps and offer additional interventions as appropriate. 

12. Risk stratification 

Use data to identify and target services to patients. 

13. Performance measurement 

Assess quality of care, total cost of care, and use of certified EHR technology.

CMS Care Plan and Service Requirements for APCM

A comprehensive care plan is essential in APCM, guiding the delivery of patient-centered care. CMS guidelines require each care plan to be tailored to address the unique needs and goals of the patient, ensuring that PCPs provide coordinated, proactive care.

Care plan requirements:

• Patient assessment: An APCM care plan begins with a thorough assessment of the patient’s physical, mental, and social health. This assessment informs all subsequent care activities.
• Personalized health goals: The care plan should outline specific, measurable goals that align with the patient’s chronic conditions and healthcare needs.
• Interdisciplinary coordination: Although only primary care providers can bill for APCM codes, the service encourages a team-based approach, involving multiple healthcare professionals, such as registered nurses and social workers, to ensure comprehensive patient support. Each team member’s role should be documented in the care plan.
• Routine reviews and updates: CMS requires that the care plan be regularly reviewed and updated, especially when there are significant changes in the patient’s health. Document any updates to ensure ongoing compliance.

An individualized care plan allows primary care providers to deliver proactive, high-quality care that meets CMS’s standards and adapts as patient needs change.

CMS Documentation Guidelines for APCM

Thorough documentation is key to meeting CMS’s APCM compliance requirements. Each patient interaction, care coordination effort, and adjustment to the care plan must be recorded to demonstrate the continuity of care and meet billing requirements.

Documentation Guidelines:

• Team collaboration notes: While only primary care providers and FQHCs/RHCs can bill using APCM codes, CMS expects documentation of contributions from each care team member, supporting the interdisciplinary nature of the care provided.
• Record of patient interactions: Document every communication with patients, including phone calls, telehealth visits, and in-person visits, to establish continuity of care.
• Patient consent: Document the initial consent to APCM services and any discussions about the care plan, costs, and benefits to maintain compliance with CMS guidelines.

Accurate, real-time documentation helps primary care providers ensure compliance and deliver quality patient care under APCM.

Integrating APCM with Remote Patient Monitoring (RPM) and Telehealth

CMS supports the integration of APCM with other Medicare services like remote patient monitoring and telehealth to provide continuous monitoring and proactive care for patients. RPM is especially valuable in APCM, allowing primary care providers to track real-time patient health data.

RPM and telehealth guidelines for APCM:

• RPM codes CPT 99457 & 99458: PCPs can bill for RPM in conjunction with APCM, using these codes for patient education and interactive communication with the care team.
• Telehealth for routine follow-ups: Telehealth can be used for non-emergency check-ins and follow-up visits, enhancing access to care for patients with mobility or transportation limitations.

Integrating RPM and telehealth with APCM enhances patient outcomes, maintains continuous engagement, and aligns with CMS’s goals for quality, patient-centered care.

24/7 Patient Access and Continuity of Care Requirements

One of the core requirements of APCM is ensuring that patients have 24/7 access to their primary care team for assistance. This around-the-clock access is crucial to providing continuous support and meeting CMS standards for APCM.

24/7 access standards:

• On-call staff availability: CMS requires PCPs to ensure that patients can reach a qualified care team member at any time, whether through on-call clinical staff or a contracted service.
• Telehealth service options for non-urgent needs: Telehealth offers patients convenient access to follow-up visits or questions, supporting continuity of care and enhancing patient satisfaction.
• After-hours protocols: Establish clear protocols for handling after-hours calls, ensuring patient concerns are addressed promptly and documented for follow-up.

Providing 24/7 care team access builds trust with patients and reinforces CMS’s focus on comprehensive, accessible care in APCM.

Best Practices for CMS APCM Compliance

CMS’s APCM guidelines emphasize quality and consistency in patient care for Medicare beneficiaries. The following best practices can help primary care providers ensure compliance and optimize the delivery of APCM services:

1. Use APCM-compliant software: Given the detailed documentation required for APCM, a robust, APCM-compliant platform can simplify time tracking, billing, and reporting, supporting compliance with CMS requirements.

2. Implement regular training for your team: As CMS updates policies, ensure that your entire care team remains informed and trained on APCM requirements and best practices for effective care management.

3. Conduct monthly compliance audits: Monthly audits of APCM documentation, care plans, and billing practices can help identify areas for improvement and prevent compliance issues.

4. Monitor patient satisfaction and engagement: Gathering patient feedback can help refine APCM service delivery, meeting CMS’s focus on patient engagement and high standards of care.

How Prevounce Supports Primary Care Providers in APCM Compliance

Prevounce offers a suite of tools and support to help primary care providers implement and manage APCM services. From care planning to documentation and billing, Prevounce makes it easier to adhere to CMS’s requirements and capture APCM revenue effectively.

Why Prevounce for APCM?

• Comprehensive remote care platform: Our platform supports end-to-end management of a variety of Medicare care management programs, including care coordination, documentation, and billing.

• Customizable care plan templates: Our platform provides templates that meet CMS’s care plan requirements, simplifying the setup and management of APCM services and easing the administrative burden of compliance.

• Seamless EHR and RPM integration: Prevounce integrates with your existing workflows, allowing for a comprehensive approach to APCM and RPM.

Prioritizing APCM Compliance

By following CMS’s APCM guidelines, primary care providers can deliver quality, patient-centered care to a wide range of Medicare beneficiaries. Understanding and implementing these guidelines not only ensures compliance but also improves patient outcomes and enhances practice revenue.

If your primary care practice is ready to implement APCM, contact Prevounce today to see how our platform can streamline your workflows, enhance compliance, and empower your team to deliver exceptional 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!