Using advanced primary care management services codes G0556, G0557 and G0558

Doctor consulting with patient

When you use new advanced primary care management codes, your practice can get appropriate payment for complex care of Medicare beneficiaries.

Like G2211, the APCM codes represent a recent effort from CMS to boost primary care.

What are advanced primary care management services?

APCM services are a new set of codes meant to provide payment for the resources associated with providing advanced primary care to patients. They bundle several existing care management and communication technology-based services, including:

  • Principal care management (CPT codes 99424-99427)
  • Chronic care management (CPT codes 99487-99491, 99437, 99439)
  • Transitional care management (CPT codes 99495-99496)
  • Interprofessional internet consultation (CPT codes 99446-99449, 99451-99452)
  • Remote evaluation of patient videos/images (HCPCS code G2250)
  • Virtual check-in codes (HCPCS codes G2251-G2252)
  • Online Digital E/M (CPT codes 98970-98972, 99421-99423)

APCM services may be reported monthly and are broken into three levels. The codes are:

  • G0556: APCM services for patients with one or fewer chronic conditions.
  • G0557: APCM services for patients with two or more chronic conditions.
  • G0558: APCM services for patients with two or more chronic conditions and who are Qualified Medicare Beneficiaries.

What are the APCM service requirements?

Practices must satisfy several service elements to bill APCM services. Many service elements align with CCM and TCM.

At a high level, the service elements include:

  • Obtain patient consent
  • Conduct an initiating visit for new patients
  • Provide 24/7 access and continuity of care
  • Provide comprehensive care management
  • Develop, implement, revise and maintain an electronic patient-centered comprehensive care plan
  • Coordinate care transitions
  • Coordinate practitioner, home- and community-based care
  • Provide enhanced communication opportunities
  • Conduct patient population-level management
  • Measure and report performance

For a full list of APCM requirements, visit the CMS APCM page.

Do all APCM service elements need to be provided each month?

Patients don't need to receive all service elements each month. CMS anticipates that all APCM elements will be routinely provided, as deemed appropriate for each patient, but not all elements may be necessary for every patient during each month. Practices must maintain their ability to provide all elements to any patient in any given month.

How often is consent required for APCM services?

Consent must be obtained before you start billing for APCM services for a patient. It only needs to be obtained once. It can be written or verbal but must be documented in the medical record. AAFP's FPM journal has a free sample consent form for APCM.

Consent must inform the patient that:

  • Only one physician or clinician may provide and be paid for APCM services during a calendar month
  • They have the right to stop services at any time
  • Cost-sharing may apply
"We got data back that one patient had been to the ER more than 40 times in the year before, and it was always on a weekend. My care manager started calling him every Friday morning to ask, ‘Do you need to be seen? Do you need any refills?’ And like that, the following year, he went to the ER maybe twice.”
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How often can APCM services be billed?

APCM services can be billed once per calendar month. Only one physician or clinician can report APCM services for a patient per month.

Since APCM services represent a bundle of existing services (see above), the physician or clinician billing APCM cannot bill both APCM and the individual services for the same patient in the same month. For example, you may report either APCM or CCM for a patient, but you cannot report both for the same patient during the same month.

Additionally, a patient may receive CCM one month and APCM the next. However, it is important to note that the consent requirements for APCM and CCM are separate. Patient consent to receive CCM services does not satisfy the APCM consent requirement and vice versa.

Who can provide APCM services?

APCM services can be billed by physicians, non-physician clinicians (e.g., nurse practitioners), physician assistants and clinical nurse specialists. Any specialty can bill APCM services, but they are aimed at primary care specialties.

By billing for APCM services, you are affirming that you are or intend to be responsible for all the patient’s primary care services and the focal point for all their needed health care services.

APCM services are designated as care management services, meaning they can be provided by auxiliary personnel under general supervision.

Can I still bill for chronic care management (CCM) or transitional care management (TCM)?

Yes, however, APCM, CCM and TCM may not be billed by the same physician or clinician for the same patient in a month. If a patient receiving APCM services qualifies for CCM or TCM in a month, the practice may choose which service they would like to report for the month.

APCM CCM Key Difference
Billing Clinician
  • Physicians, nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists
  • Services are designated as “care management” and can be provided by auxiliary staff under the general supervision
  • Is or intends to be responsible for the patient’s primary care services and services as the continuing focal point for all needed health care services
  • Physicians, nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists
  • Services are designated as “care management” and can be provided by auxiliary staff under the general supervision
  • The clinician billing for APCM services must be or intend to be responsible for the patient’s primary care services and serve as the continuing focal point for all needed health care services
Consent
  • Verbal or written consent documented in medical record before initiating APCM services
  • Obtained once, unless patient switches to a different physician or clinician
  • Consent must inform patient of:
    • Possible cost-sharing responsibilities
    • Only one clinician may provide and bill APCM during a calendar month
    • Right to stop APCM services at any time
  • Verbal or written consent documented in medical record before initiating CCM services
  • Obtained once, unless patient switches to a different physician or clinician
  • Consent must inform patient of
    • Availability of CCM services
    • Possible cost-sharing responsibilities
    • Only one clinician may provide and bill CCM during a calendar month
    • Right to stop CCM services at any time
 —
Initiating Visit
  • Required for new patients or if patient has not been seen in practice within previous three years or has not received another care management service from the practice within the previous year
  • Can happen during an evaluation and management visit, annual wellness visit or initial preventive physical exam
  • Required for new patients or patients not seen within the previous year
  • Can happen during an evaluation and management visit, annual wellness visit or initial preventive physical exam
  • An initiating visit for APCM services is only required for patients who have not been seen in the practice within the previous three years
Eligible Beneficiaries
  • All Medicare beneficiaries for whom the billing physician or clinician has assumed or intends to assume responsibility for all primary care services and serves as the continuing focal point for all needed health care services
  • Medicare beneficiaries with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline
  • APCM is not limited to beneficiaries with chronic conditions
Time Threshold
  • None
  • Non-complex CCM
    • Provided by clinical staff (CPT code 99490): 20 minutes
    • Personally provided by physician (CPT code 99491): 30 minutes
  • Complex CCM
    • Provided by physician or clinical staff (CPT code 99487): 60 minutes
  • Time thresholds eliminated for APCM services.
  • APCM codes are not stratified by who directly performs the service (i.e., clinical staff or physician) 
Access to Care and Care Continuity
  • Provide 24/7 access to care team/clinician, including providing patients/caregivers with a way to contact health care professionals to discuss urgent care needs no matter the day or time. Afterhours communication must be documented and communicated to the primary care team/clinician
  • Provide continuity of care with a designated care team member with whom the patient can schedule routine appointments
  • Deliver care in alternative ways to traditional office visits to best meet the patient’s needs, such as home visits and/or expanded hours, as appropriate
  • Provide 24/7 access to physicians or other qualified practitioners or clinical staff, including providing patients/caregivers with a way to contact their health care clinicians to discuss urgent needs no matter the day or time
  • Provide continuity of care with a designated care team member with whom the patient can schedule routine appointments and who’s regularly in touch with the patient to help them manage their chronic conditions
  • Practices reporting APCM must offer alternative ways to receive care, such as home visits or expanded hours
Comprehensive Care Management
  • Assess the patient’s medical, functional and psychosocial needs
  • Make sure the patient gets timely recommended preventive services
  • Review medications and any potential interactions
  • Oversee the patient’s medication self-management
  • Assess the patient’s medical, functional and psychosocial needs
  • Make sure the patient gets timely recommended preventive services
  • Review medications and any potential interactions
  • Oversee the patient’s medication self-management
 —
Patient-centered Comprehensive Care Plan
  • Develop, implement, revise and maintain an electronic patient-centered comprehensive care plan
  • Care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary’s care
  • Care team/clinician can routinely access and update care plan
  • Provide patients and caregivers with a copy of the care plan
  • Create, revise and monitor a person-centered, electronic care plan based on physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports
  • Care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary’s care
  • Provide patients and caregivers with a copy of the care plan
 —
Management of Care Transitions
  • Manage care transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an ED visit, or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities, as applicable
  • Timely exchange of electronic health information with other practitioners and providers to support continuity of care
  • Timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after ED visits and discharges from hospitals, skilled nursing facilities or other health care facilities within seven calendar days of discharge, as clinically indicated
  • Manage care transitions between and among health care providers and settings, including referrals to other clinicians, or follow-up after an ED visit, or follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities
  • Create and exchange or share continuity of care documents promptly with other practitioners
  • APCM requires practices to make reasonable efforts to provide timely follow-up communication after discharge from an ED visit, hospital, skilled nursing facility or other health care facility within seven days when possible.
  • APCM requires timely exchange of electronic health information but is not specific as to type (e.g., continuity of care documents)
Practitioner, Home- and Community-based Care Coordination
  • Ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals and skilled nursing facilities (or other health care facilities), as applicable
  • Documented communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences and desired outcomes, including cultural and linguistic factors
  • Ongoing
  • APCM services include expanded ongoing communication and coordination (additions in italic):
    • Home-based service providers
    • Community-based service providers
    • Community-based social service providers
    • Clinicians
    • Hospitals
    • Skilled nursing facilities
    • Other health care facilities
  • APCM services include expanded documented communication (additions in italic):
    • Psychosocial needs
    • Functional deficits
    • Goals
    • Preferences
    • Desired outcomes, including cultural and linguistic factors
Enhanced Communication Opportunities
  • Provide patients and caregivers with enhanced opportunities to communicate with the care team/clinician about their beneficiary’s care through asynchronous non-face-to-face consultation methods such as email, internet or patient portal
  • Provide communication technology-based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/EHR referral service(s), to maintain ongoing communication with patients, as appropriate
  • Ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and E/M visits (or e-visits) 
  • Provide patients and caregivers with a way to communicate about their care by phone and through secure messaging, secure web or other asynchronous non-face-to-face consultation methods (like email or a secure electronic patient portal)*

*—This element appears under Access and Continuity for CCM
  • APCM services additional communication technology-based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/EHR referral service(s), to maintain ongoing communication with patients, as appropriate
  • APCM services include access to patient-initiated digital communications that require a clinical decision
Patient Population-level Management
  • Analyze patient population data to identify gaps in care and offer additional interventions, as appropriate
  • Risk-stratify the practice population based on defined diagnoses, claims or other electronic data to identify and target services to patients
  • N/A
  • New requirement
Performance Measurement
  • Be assessed on primary care quality, total cost of care and meaningful use of certified EHR technology by either:
    • Registering and reporting the Value in Primary Care MIPS Value Pathway
    • Participating in a Medicare Shared Savings Program ACO, Realizing Equity, Access, and Community Health ACO, Making Care Primary, or Primary Care First 
  • N/A
  • New requirement

Who is eligible for APCM services?

Any patient may receive APCM services. There are three levels of APCM services. The level billed will depend on the number of chronic conditions a patient has (including none) and whether they are a Qualified Medicare Beneficiary (QMB). The three levels are:

  • Level 1: G0556, patients with one or fewer chronic conditions
  • Level 2: G0557, patients with two or more chronic conditions
  • Level 3: G0558, patients with two or more chronic conditions and who are Qualified Medicare Beneficiaries

The definition of a chronic condition aligns with definition used for CCM. The condition must be expected to last at least 12 months or until the death of the patient and place the patient at significant risk of death, acute exacerbation/decompensation or functional decline.

What is a Qualified Medicare Beneficiary?

The QMB Program provides coverage of Medicare Part A and Part B premiums and cost-sharing to low-income beneficiaries. Individuals with QMB status cannot be billed for cost-sharing. Additional information related to the prohibition on billing QMBs can be found here.

There are several ways to verify whether an individual is a QMB, including:

Contact your Medicare Advantage plans to learn how to identify the QMB status of their members.

Do other payers cover APCM services?

Coverage by private payers (including Medicare Advantage) and Medicaid varies. Check with your local provider relations representatives regarding their coverage.

How much do APCM codes pay?

The 2025 Medicare Physician Fee Schedule average national allowable amounts are:

  • G0556 (patients with one or fewer chronic conditions): $15.20
  • G0557 (patients with two or more chronic conditions): $48.84
  • G0558 (patients with two or more chronic conditions and who are Qualified Medicare Beneficiaries): $107.07

Does cost-sharing apply?

Yes, although it may be covered by a patient’s supplemental plan. As part of the consent process, you must ensure the beneficiary is aware that cost-sharing applies. Cost-sharing includes deductible, copay and coinsurance.

Can I bill APCM codes in an alternative payment model?

Practices participating in Primary Care First (PFC) and Making Care Primary (MCP) can report APCM services for the 2025 model year. The APCM services will be paid at the physician fee schedule rates (listed above).

When should APCM codes be billed?

APCM may be billed at any point during the calendar month. Practices will need to assess their billing workflows to determine how they would like to bill APCM services. As you review your workflow, you may want to consider:

  • if you will continue to report CCM or TCM services if a patient qualifies during the month. Billing APCM services at the beginning of the month would preclude you from reporting CCM or TCM for a patient for the month,
  • how timing may impact your patients since they may be responsible for cost-sharing.

Do I need to attest to meeting each APCM service element?

No. CMS indicated in the 2025 Medicare Physician Fee Schedule Final Rule that billing for APCM services would be interpreted as an attestation that the service meets the requirements specified in the code descriptor.

What are the documentation requirements?

CMS has not published detailed documentation guidance. While practices do not need to document that they meet the ACPM service capabilities, documentation should adequately reflect the applicable APCM services delivered to the patient during the month that APCM is billed (e.g., patient interactions with the care team, updates to the person-centered care plan, communications with other health care providers, etc.).

How do I get started providing APCM services?

Care management is a foundational element of APCM services. If you're already providing chronic care management and transitional care management services, you likely have many APCM service elements already in place.

Review the APCM requirements and determine which elements require new workflows or whether you need to make modifications to your existing workflows. Make sure you obtain a separate consent for APCM, as separate consent for CCM and APCM services is required.

About CCM coding

Review five CPT codes used to report CCM services.

About TCM coding

Review two CPT codes used to report TCM services.

Risk stratification tools

Use a rubric and algorithm designed to help you make care decisions that improve health and reduce costs.

More APCM resources