Healthcare reimbursement is driving a shift toward more comprehensive and coordinated care models. To support this transition, the Centers for Medicare & Medicaid Services (CMS) introduced Advanced Primary Care Management (APCM) codes in the CY 2025 PFS final rule (PFS) final rule. APCM codes for 2025 simplify care management, enhance provider reimbursement, and promote a more holistic approach to primary patient care.
The article will explain the new APCM codes in 20205 introduced by CMS in the CY 2025 Physician Fee Schedule (PFS) final rule.
It will cover:
- The purpose of APCM codes – How they support value-based care and integrate chronic, principal, and transitional care management.
- Differences between APCM and chronic care management (CCM).
- Billing requirements and reimbursement structure – Breaking down the three-tiered APCM codes (G0556, G0557, G0558).
- Benefits of APCM – How it simplifies care coordination, enhances financial sustainability, and improves patient outcomes.
- The future of APCM – How providers can leverage these codes alongside remote monitoring technologies for better patient care and reimbursement.
What is APCM?
By integrating elements of chronic care, principal care, and transitional care management, Advanced Primary Care Management codes 2025 offer flexibility and financial sustainability in delivering value-based care in the following ways.
- Comprehensive assessments to evaluate medical, functional, and psychosocial needs.
- Integrated care plans addressing chronic, single-condition, and transitional care management.
- Preventive care coordination to reduce redundancies and improve continuity of care.
- All-hour access to care teams to ensure patient-centered care.
What Are APCM Codes for 2025?
APCM codes 2025 refer to billing codes used by healthcare providers to document and receive reimbursement for enhanced care management. This new model, referred to as an enhanced care management model, is similar to chronic care management (CCM) but functions more like a value-based care program.
Unlike CCM, APCM codes 2025 follow a flat reimbursement rate with no minimum time requirement, regardless of the time spent. This shift in approach focuses on care coordination rather than meeting specific time thresholds.
Differences Between CCM and APCM
Understanding the distinctions between chronic care management and APCM codes in 2025 is crucial. While both models work to improve patient outcomes through coordinated care, APCM expands beyond CCM. It by incorporates additional care management services, refining performance measurement, and offering a different billing structure. Below are the key differences between the two programs.
Scope of Services
CCM focuses solely on chronic care management, while APCM integrates principal care management (PCM) and transitional care management (TCM), expanding the scope of patient services. APCM emphasizes identifying and addressing gaps in care, enabling proactive patient intervention and tailored care delivery. Depending on the type of organization, reimbursement may require additional reporting and preparation compared to CCM.
Billing Requirements for APCM Codes in 2025
CCM relies on a single-level code, while APCM codes for 2025 use a tiered structure based on the complexity of care provided.
To bill for APCM codes in 2025, practices must be equipped to provide all 13 APCM service elements, though not every element is required each month. This flexibility allows customization based on patient needs rather than time spent.
Requirements include:
- No time-based thresholds, unlike CCM and PCM services.
- Cannot be billed concurrently with CCM, PCM, or TCM services.
- Remote physiologic and therapeutic monitoring (RPM and RTM) services are separately billable.
- Patient consent is required before billing for APCM services.
What Are the APCM Codes 2025?
APCM codes follow a three-tiered structure:
- G0556 (Level 1): $15 per month for patients with one chronic condition or no chronic conditions but specific service bundle requirements.
- G0557 (Level 2): $50 per month for patients with two or more chronic conditions.
- G0558 (Level 3): $110 per month for Qualified Medicare Beneficiaries (QMB) with two or more chronic conditions. Medicare providers cannot bill QMB patients directly.
CCM generally pays more than APCM Levels 1 and 2, but APCM Level 3 exceeds CCM rates. Providers can alternate between CCM and APCM programs but cannot use both for the same patient within the same month.
Benefits of Using APCM
The introduction of APCM codes 2025 merges multiple care management programs into a single framework, providing:
- Streamlined care delivery for better patient outcomes.
- Simplified billing processes with a tiered structure.
- Comprehensive care coordination that integrates chronic, single-condition, and transitional care.
- 24/7 patient access to their care team, a critical component of patient-centered care.
- Caregiver support, allowing training services as reimbursable activities.
The Future of APCM Codes 2025
As virtual care expands, APCM codes 2025 will remain integral to modern healthcare reimbursement. By staying informed and integrating automated remote monitoring technologies, providers can maximize the benefits of APCM while enhancing patient care and financial sustainability.
