01/18/2025
APCM - Advanced Primary Care Management
Last Updated December 09, 2024
CMS finalized new services for Advanced Primary Care Management (APCM), effective January 1, 2025, for Medicare beneficiaries.
Background
According to CMS, advanced primary care delivery models involve costs associated with maintaining certain practice capabilities and continuous readiness and monitoring activities to support a team-based approach to care, where significant resources are used on virtual, asynchronous patient interactions, collaboration, and real-time management of patients that are not fully accounted for by the existing care management codes.
APCM codes include three levels
Level 1
HCPCS Code G0556
Beneficiaries with 1 or fewer chronic conditions
Level 2
HCPCS Code G0557
Beneficiaries with 2 or more chronic conditions
Level 3
HCPCS Code G0558
Qualified Medicare Beneficiaries with 2 or more chronic conditions
When to Bill APCM Services
APCM services may be billed by a physician or NPP who is responsible for all primary care and serves as the continuing focal point for all needed health care services for the beneficiary. Care may be delivered by auxiliary personnel under the billing practitioner’s direction and general supervision. Qualified practitioners who meet the required practice-level capabilities/service elements identified below may bill 1 APCM service code per month.
*Note that the same practitioner cannot bill APCM concurrently with CCM, PCM, TCM, interprofessional consultation, remote evaluation of patient videos/images, virtual check-in, and e-visits
Required Practice-Level Capabilities/Service Elements
Billing practitioners must have the ability to furnish every service element below.
Consent
Includes availability of APCM services; that only one practitioner can be paid for these services during a calendar month; right to stop services at any time (effective at the end of the calendar month); and cost sharing
Initiating Visit
Required for new patients or patients not seen within 3 years. Can be furnished during an E/M visit, IPPE, AWV or TCM service.
24/7 Access to Care and Care Continuity
Provide reasonable after-hour care, when necessary.
Designate member of the care team for scheduling routine appointments; Offer alternatives to traditional office visits to best meet the patient’s needs, such as home visits and/or expanded hours, as appropriate
Overall Comprehensive Care Management
Systematic needs assessment (medical and psychosocial);
System-based approaches to ensure receipt of preventive services; Medication reconciliation, management and oversight of self-management
Comprehensive Care Plan
Development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan
Management of Care Transitions
Coordination of care transitions for hospital discharges, ED visit follow-up, referrals, as applicable; Timely exchange of EHR information with other providers; Follow-up communication with the patient and/or caregiver within 7 calendar days of discharge, as clinically indicated whenever possible
Care Coordination
Ongoing communication and coordinating receipt of needed services from practitioners, home- and community based service/social service providers, hospitals, and skilled nursing facilities (or other health care facilities), as applicable, and document communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors in the patient’s medical record
Enhanced Communication Opportunities
Asynchronous non-face-to-face consultation methods other than telephone (secure messaging, email, internet, or patient portal, and other communication technology-based services), including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/EHR referral service(s); 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)
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
A practitioner who is participating in a Shared Savings Program ACO, REACH ACO, Making Care Primary, or Primary Care First satisfies this requirement.
Performance Measurement
Assessed on primary care quality, total cost of care, and meaningful use of CEHRT. This requirement is satisfied for MIPS-eligible clinicians, by registering for and reporting the Value in Primary Care MVP and/or by participating in a Shared Savings Program ACO , REACH ACO, Making Care Primary, or Primary Care First.
Patient Cost Sharing
Patient coinsurance and deductible applies
Documentation Requirements
Any actions or communications that fall within the APCM elements of service should be documented in the medical record and, as appropriate, its relationship to the clinical problem(s) they are intended to resolve and the treatment plan.
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