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The Center for Medicare & Medicaid Services (CMS) issued the of the final Calendar Year 2025 Physician Fee Schedule on November 1, 2024, which included three new Healthcare Common Procedure Coding System (HCPCS) codes for advanced primary care management (APCM). The new APCM codes will take effect on January 1, 2025.

Over the last decade, the CMS Innovation Center has tested over 50 payment and service delivery models designed to stabilize the cost of care and increase quality. Consistent with the U.S. Department of Health and Human Services’ (HHS) “Initiative to Strengthen Primary Health Care,” CMS conducted a retrospective review of the more successful programs related to primary care. Based on its analysis, CMS determined that primary care practitioners needed additional and separate compensation for time spent on care management and coordination outside of evaluation and management visit, resulting in three APCM codes.

The APCM Codes

The three APCM codes generally have the same basic requirements for the billing practitioner, however, they vary based on patient complexity:

Unlike the five non-complex and complex chronic care management (CCM) and principal care management (PCM) codes finalized by CMS since 2013 (which are billed based on time spent by the practitioner), the APCM codes are billed monthly and are not tied to a specific number of minutes. The APCM codes also differ from the Comprehensive Primary Care, Comprehensive Primary Care Plus, and Primary Care First programs run through the CMS Innovation Center, which all paid practices a prospective, monthly payment per Medicare beneficiary. However, CMS intentionally designed the APCM services to be consistent with certain existing codes because the complex overlapping patient populations have similar management needs. Therefore, practitioners in the same practice cannot bill APCM codes concurrently with fifteen overlapping codes for CCM, PCM, communication technology-based service, and transitional care management. Examples of these overlapping services include interprofessional specialist consults, remote evaluation videos and images submitted by patients, virtual check-ins, and communications between patients and practitioners through an online portal.

Requirements to Bill

To bill the APCM codes, the following requirements must be satisfied:

1. Patient consent (inform the patient of the services, their right to stop, and of the potential cost sharing obligations[1]);
2. Initiating visit (required for new patients and patients not seen by the practice in the last three years);
3. 24/7 access and continuity of care (access to team member for urgent needs at all times and continuity through the use of a dedicated team member);
4. Comprehensive care management (systematic needs assessment, system-based approaches to ensure preventative services are provided, and medication reconciliation, and oversight of patient self-management of medications);
5. Patient-centered comprehensive care plan (the plan should be timely available to those involved with a patient’s care, routinely updated, and provided to the patient and/or caregiver);
6. Management of care transitions (ensuring timely exchange of electronic health information and patient follow-up after emergency room visits and hospital discharges);
7. Practitioner, home-, and community-based care coordination (coordinated referral management with specialists and other health care organizations through developing processes and procedures in the form of collaborative care agreements and electronic consultations);
8. Enhanced communication opportunities (for patients and caregivers to communicate with team members through additional asynchronous methods);
9. Patient population-level management (manage preventative and chronic care for the practice’s patient population and develop and implement strategies to improve outcomes); and
10. Performance measurement (quality, cost of care, and meaningful use of certified electronic health records technology).

Some of these requirements may be satisfied by participation in another CMS program. For example, the initiating patient requirement is consistent with the standards for the Shared Savings Program, ACO REACH Model, Making Care Primary, and Primary Care First. Therefore, the billing practitioner will generally meet the ACPM initiating visit requirement by virtue of participating in one of these four programs. Similarly, the practice-level performance measurements substantially overlap with the reporting requirements for the Shared Savings Program, REACH ACO, Primary Care First, Making Care Primary, and Merit-based Incentive Payment System eligible practitioners who report the Value in Primary Care MVP. As such, billing practitioner will meet the practice-level ACPM reporting requirements if they participate in and report the metrics required for participating in these existing programs.

Team Based Approach for Successful Care Management

APCM encourages a team-based approach that allows for accessibility and alternative methods for patients to communicate with the primary billing practitioner and auxiliary personnel outside of in-person visits. For example, while the APCM codes can only be reported once a calendar month per patient, the billing practitioner can change from month to month based on the actual physician, nurse practitioner, physician assistant, certified nurse midwife or clinical nurse specialist assumes the management role during that period. Designated care management services can also be performed by auxiliary personnel under general supervision of the billing practitioner.

Conclusion

While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing. HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.

Payor/Provider Convergence Blog Series

For additional resources on the intersection of payor/provider convergence and the issues that plague insurance and health companies, payors, and providers, click here to read the other articles in our series.

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[1] These codes do not qualify as additional preventative services at this time; therefore, coinsurance obligations still apply.