Advance Primary Care Management (APCM) and Who Can Bill For It

Advanced Primary Care Management (APCM), which started in 2025, is the latest care management program from CMS. Unlike older care management plans, it supports every Medicare beneficiary, irrespective of how many chronic conditions they have. As APCM is just starting, many people have questions about requirements, billing, and codes.

APCM Billing Codes

Advanced Primary Care Management has three codes that can be billed:

• G0556: Any Medicare patient who signs up for APCM services can be billed for this code, whether they have one or no chronic conditions.
• G0557: Only eligible for Medicare patients who opt for APCM services and have two or more chronic diseases.
• G0558: Can only be claimed for Medicare patients with two or more ongoing health problems who are also Qualified Medicare Beneficiaries. 

People who are Qualified Medicare Beneficiaries do not have to pay a copay for APCM services. You are allowed to bill a code just once for each patient, every month. If a patient’s level is adjusted, you should change the corresponding code and inform them that their copay may be different.

Eligibility for Billing Advance Primary Care Management Services

Various providers can bill for APCM.

Physicians

• Nurse practitioners 
• Physician assistants
• Clinical nurse specialists

But to get paid for APCM, the provider must also:

• Make sure all of a patient’s basic health care needs are met.
• Handle all the healthcare services that a patient uses.
• Have been given permission by the patient in writing or verbally
• As a result, APCM programs are generally accessible to primary care or family medicine doctors, since they often act as the main point of care for a patient.

Though the provider is in charge of the APCM program, they can delegate the actual services to others. Clinical staff may offer the services under the broad oversight of the provider when they are provided in conjunction with the provider’s own care.

Requirements for APCM Service

Unlike Chronic Care Management or Primary Care Management, Advanced Primary Care Management does not require dedicated time each month. Practices are able to bill for APCM if they offer all the services needed by the patient, even if the patient did not use them that month.

APCM’s services allow patients to take charge of their health and manage their health problems by themselves between medical visits. With APCM, clinicians can change their services to fit what patients require, rather than trying to stay within time limits. 

The required service elements for APCM are:

• Getting patients’ consent before starting any APCM services
• A visit to establish care for the first time. Individuals seen within the last three years can skip the initiating visit.
• You can access care any time of day or night.
• Comprehensive care involves evaluating needs, using preventive services for groups, and managing and organizing medications
• An electronic plan is made for each patient
• Check on patients within a week of them leaving the hospital or emergency department
• Bringing together care at the doctor’s office, at home, and in the community with the help of the provider
• These options include text, email, or patient portal, all of which are asynchronous and digital
• Managing patients on a population level, focusing on what care is missing and how to group patients by risk 
• Performance can be measured and reported using the Value in Primary Care MIPS Value Pathway (MVP), an ACO or an Advanced Alternative Payment Model.

Reimbursement Rates for APCM Codes

Because APCM has three different levels for patients, it also has three different billing codes, with different reimbursement rates for each.

CPT code G0556

On average, CPT Code G0556 is reimbursed $15 each month for patients who have one or no chronic conditions. The amount you receive as reimbursement is set by your state. 

CPT Code G0557

The average reimbursement rate for G0557, which describes patients with two or more chronic conditions, is $50 per patient, per month. The amount a person receives back will differ by state. 

CPT Code G0558

The standard reimbursement rate for CPT Code G0558, which refers to patients with two or more chronic illnesses who are also Qualified Medicare Beneficiaries, is $110 per month, per patient. The amount you can be reimbursed depends on where you live.

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