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 patient eligibility to documentation and billing, so your primary care practice can implement an effective, compliant APCM program.
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.
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.
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.
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 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.
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.
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.
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.
Accurate, real-time documentation helps primary care providers ensure compliance and deliver quality patient care under APCM.
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.
Integrating RPM and telehealth with APCM enhances patient outcomes, maintains continuous engagement, and aligns with CMS’s goals for quality, patient-centered care.
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.
Providing 24/7 care team access builds trust with patients and reinforces CMS’s focus on comprehensive, accessible care in APCM.
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:
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.
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.
Conduct monthly compliance audits: Monthly audits of APCM documentation, care plans, and billing practices can help identify areas for improvement and prevent compliance issues.
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.
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.
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.
Seamless EHR and RPM integration: Prevounce integrates with your existing workflows, allowing for a comprehensive approach to APCM and RPM.
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.