Advanced Primary Care Management Management (APCM) is a valuable Medicare service that allows primary care providers (PCPs) to deliver ongoing, coordinated care for Medicare patients. APCM represents an opportunity for practices and federally qualified health centers (FQHCs) to increase revenue, as it compensates providers for their care management efforts each month. When combined with remote patient monitoring (RPM), the revenue potential of APCM expands even further, providing a strong return on investment (ROI) for practices and FQHCs.
In this post, we’ll explore how APCM can enhance provider revenue, break down the new APCM billing codes, share an example of projected ROI, and explain how adding RPM can further boost earnings.
CMS created three APCM HCPCS billing codes to recognize the various complexities involved in patient management. Each code reflects a different level of patient care complexity and corresponding reimbursement:
APCM billing codes and reimbursement rates:
HCPCS G0556: APCM for patients with up to one chronic condition. Approximate reimbursement is $15.
HCPCS G0557: APCM for patients with multiple chronic conditions. Approximate reimbursement is $50.
HCPCS G0558: APCM for patients who are Qualified Medicare Beneficiaries (QMBs) with multiple chronic conditions. Approximate reimbursement is $110.
These three G-codes allow providers to receive recurring monthly payments for Medicare patients, with higher reimbursement rates for more complex cases.
To illustrate the revenue potential of APCM, let’s look at a hypothetical example of an organization with 1,000 Medicare patients.
Scenario:
Eligible patient population: 1,000 Medicare patients.
400 patients with one or zero chronic conditions (G0556)
500 patients with multiple chronic conditions (G0557)
100 high-need patients with QMB status and multiple chronic conditions (G0558)
Revenue calculation for APCM services only:
G0556:
400 patients x $15 (G0556 rate) = $6,000 per month
G0557:
500 patients x $50 (G0557 rate) = $25,000 per month
G0558:
100 patients x $110 (G0558 rate) = $11,000 per month
Total monthly APCM revenue: $6,000 (G0556) + $25,000 (G0557) + $11,000 (G0558) = $42,000
Annual APCM Revenue: $42,000 x 12 months = $504,000
For a primary care practice or FQHC managing 1,000 APCM patients, the Medicare service alone can yield more than half a million dollars in annual revenue. This provides a consistent — and possibly much-needed — income stream while enhancing care management services for patients.
Remote patient monitoring (RPM) complements APCM by allowing continuous tracking of patient health metrics. Integrating RPM with APCM not only provides data-driven care but also creates additional revenue opportunities.
RPM billing codes and reimbursement rates:
CPT 99453: Covers initial setup and patient education for RPM devices. Approximate reimbursement is $19 (billed once per patient).
CPT 99454: Covers monthly data transmission and monitoring. Approximate reimbursement is $47 per patient per month.
CPT 99457: Covers the first 20 minutes of interactive communication with the patient via RPM each month. Approximate reimbursement is $48.
CPT 99458: An add-on code for each additional 20 minutes of interactive RPM communication. Approximate reimbursement is $39.
RPM revenue example for the same patient population:
RPM device monitoring and setup:
1,000 patients x $19 (CPT 99453, setup) = $19,000 for initial setup (one-time)
Monthly RPM monitoring (99454):
1,000 patients x $47 (CPT 99454) = $47,000 per month
RPM communication (99457):
1,000 patients x $48 = $48,000 per month
Annual RPM Revenue Calculation:
Monthly RPM revenue = $47,000 + $48,000 = $95,000
Annual RPM revenue = $95,000 x 12 = $1,140,000
Total first-year RPM revenue (including setup):
$1,140,000 (monitoring) + $19,000 (setup) = $1,159,000
Integrating RPM with APCM allows practices and FQHCs to capitalize on both services, enhancing patient care while increasing practice revenue. For our 1,000-patient example:
Total annual revenue = $1,663,000
For a practice or FQHC managing 1,000 patients with APCM and RPM, this combined approach could yield over $1.6 million in additional revenue annually.
To maximize the revenue and clinical benefits of APCM and RPM, consider the following strategies:
Streamline patient identification: Use tools to identify Medicare patients and then those eligible for RPM, especially those with chronic conditions who may benefit from continuous monitoring.
Educate patients on APCM and RPM benefits: Ensure patients understand the advantages of APCM and RPM in managing their chronic conditions. Informed patients are more likely to adhere to their care plans and engage with RPM devices.
Utilize automated documentation tools: Software solutions like Prevounce can help track and document APCM services and track and document time spent on RPM services, better ensuring compliance and appropriate, complete billing.
Establish clear communication protocols: Set up workflows to manage RPM alerts within the APCM framework. Having a system in place to address abnormal readings promptly improves patient outcomes and demonstrates the value of RPM.
Prevounce provides tools to simplify APCM and RPM implementation, making it easier to track billable activities, document patient interactions and services, and integrate RPM data into APCM workflows. With Prevounce, practices can enhance patient care, better ensure CMS compliance, and maximize revenue potential.
Automated documentation and time tracking: Capture all billable services, time, and documentation effortlessly, ensuring full compliance and accurate, complete billing.
Seamless RPM integration: Easily manage RPM data within the APCM framework, streamlining workflows and improving patient outcomes.
Patient engagement tools: Educate and engage patients in their APCM and RPM plans, fostering active participation and better health outcomes.
APCM and RPM present significant revenue opportunities for practices and FQHCs, offering monthly reimbursements for managing patient care more proactively. By implementing APCM and adding RPM, practices can improve patient outcomes while generating a steady, high-value revenue stream.
Ready to boost your practice or FQHC revenue through APCM and RPM? Contact Prevounce today to see how our platform can support your organization's financial and clinical goals.