Primary care practices now have a simpler way to get paid for time spent managing patients' care between visits, including behavioral health care.
Family medicine practices have long delivered comprehensive care coordination, proactive patient outreach, and technology-enabled communication — often without direct reimbursement for this ongoing work between visits. Medicare's “advanced primary care management” (APCM) program, which launched in 2025, is intended to simplify and broaden payment for this important work.
Unlike the G2211 add-on complexity code, APCM codes are designed for primary care only. The primary care office serves as the continuing focal point for the patient's care, and its clinical staff furnish monthly care management services under the direction of a physician or other qualified health care professional (the billing clinician). By bundling these services into a per-patient monthly payment, APCM is designed to reduce administrative burden compared with using multiple stand-alone care management codes and communication technology codes, many of which require tracking time spent. In addition, APCM expands patient eligibility for care management services to nearly the entire Medicare panel and allows practices to bill add-on codes for psychiatric collaborative care management (discussed later in the article).1–3
Successful APCM implementation relies on having clear processes in place to meet the billing requirements, especially around patient consent, eligibility verification for the dual-eligible level, and avoidance of duplicative billing.
KEY POINTS
- APCM bundles care management, technology-enabled communication, and population health into three Medicare HCPCS codes (G0556-G0558), which are not time-based but billed monthly by the clinician responsible for a patient's primary care.
- APCM requires a repeatable workflow, including eligibility checks, an initiating visit such as an AWV, one-time patient consent, creation of an electronic patient-centered care plan, and appropriate care manager outreach between visits.
- For behavioral health issues beyond the scope of APCM, practices can use add-on codes for psychiatric collaborative care management (G0568-G0570).
APCM CODES AND REQUIREMENTS
APCM coding has three levels — G0556-G0558 — based on complexity of service and whether the patient is a Qualified Medicare Beneficiary (QMB). The QMB program is administered by each state's Medicaid office but covers Medicare premiums, deductibles, coinsurance, and co-payments for low-income individuals who are disabled or age 65 or older. See Table 1 for code descriptions, relative value units (RVUs), and payment rates.
TABLE 1. APCM SERVICE LEVELS AND PAYMENT
| Code | Description | Work RVUs | Total non-facility RVUs | Approximate non-facility 2026 payment (per member per month) |
|---|---|---|---|---|
| G0556 | One or fewer chronic conditions | 0.25 | 0.49 | $16 |
| G0557 | Two or more chronic conditions | 0.77 | 1.61 | $54 |
| G0558 | Qualified Medicare Beneficiaries (dual eligible) with two or more chronic conditions | 1.67 | 3.51 | $117 |
Note: Payment amounts are approximate national averages.
Practices should verify dual-eligible/QMB status before billing G0558 and recheck regularly (e.g., at each visit or at least monthly at the time of charge submission).
Clinical eligibility. Physicians may provide APCM for patients with chronic conditions expected to last at least 12 months or until the patient's death. These conditions place the patient at significant risk of acute exacerbation/decompensation, functional decline, or death. Physicians may also provide APCM for patients without chronic conditions who are high risk and need proactive care.
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