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APCM Billing Codes and How to Use Them

Advanced Primary Care Management (APCM), launched in 2025, is CMS’s newest care management program. Unlike previous care management programs, it extends care to all Medicare beneficiaries, regardless of their number of chronic conditions. But because APCM is so new, it comes with many questions, especially about requirements, billing, and codes.

APCM has three levels of care for patients. Each level has a different billing code and different reimbursement amount, based on how much care patients at that level are likely to require. While this leads to more personalized care for each patient, it can also lead to confusion over billing. 

However, APCM also offers exciting opportunities: the ability to offer preventative care to more patients, lower their risk of hospital readmissions, and reduce their healthcare costs, while building revenue for your practice.* In this article, we’ll cover what the three APCM billing codes are, what services they include, and how you can bill the new codes compliantly, so your practice can successfully launch this new program. 

*Results may vary by provider. 

Introduction to Advanced Primary Care Management

Advanced Primary Care Management offers all Medicare patients the opportunity to receive preventative care between appointments with their provider. The program includes dedicated care managers who support patients in setting and achieving their healthcare goals.

APCM also includes:

• A 24/7 care line for patient questions
• A personalized care plan for each patient
• Directions to community resources
• Assistance with appointment scheduling
• Medication management or adherence
• Identification of gaps in care and population health needs
• Support when patients leave the hospital or ER

This ongoing care helps providers form strong connections with their patients and receive faster notifications when a patient needs an appointment or has been discharged from the hospital. It can also help practices address gaps in care, leading to improved quality scores, and can generate monthly, recurring revenue.* 

But to receive the reimbursements they’ve earned, practices must navigate APCM’s new HCPCS codes and compliantly bill them. We’ll break down the codes used with Advanced Primary Care Management, the definition and eligibility criteria for each, and how you can bill them accurately. 

*Results may vary by provider. 

APCM Billing Codes

Advanced Primary Care Management has three codes that can be billed:

• G0556: Can be billed for any Medicare patient who enrolls in APCM services, including patients who have one or no chronic conditions.
  
• G0557: Can only be billed for Medicare patients who enroll in APCM services and have two or more chronic conditions.
  • These conditions must be expected to last at least 12 months or until the death of the patient
  • These conditions must place the patient at increased risk of exacerbation or decline
    
• G0558: Can only be billed for Medicare patients with two or more chronic conditions who are also Qualified Medicare Beneficiaries. 
  • Qualified Medicare Beneficiaries have no copay for APCM services

You can bill one code per patient, per month. If a patient changes levels, you must adjust the code accordingly and let the patient know that their copay may change. 

For example, if a patient who was previously billed under G0557 applies for and is accepted into the QMB program, they will move to code G0558 and no longer have a copay. If you partner with a full-service APCM partner like ChartSpan, we can help you assign patients to the correct code and adjust codes when needed. 

Who Can Bill for Advanced Primary Care Management?

A range of providers can bill for APCM, including:

• Physicians
• Nurse practitioners 
• Physician assistants
• Clinical nurse specialists
  

However, to bill for APCM, the provider must also:

• Be responsible for all of a patient’s primary care services
• Serve as the focal point for all of a patient’s needed healthcare services
• Have received written or verbal consent from the patient

This means APCM programs are mostly available to primary care or family medicine providers, who are likely the central point of care for a patient.

While the provider must oversee the APCM program, they do not have to directly perform APCM’s services. Clinical staff can provide the services under general supervision, incident to the provider’s services. 

What Activities Can Clinical Staff Perform for APCM?

According to CMS, clinical staff members can perform Advanced Primary Care Management services. The provider who serves as the focal point of care will provide general supervision for these staff members, who can be employees of the provider’s office or contracted by the provider’s office. 

In ChartSpan’s case, we are contracted by providers to offer APCM remotely. ChartSpan employs care managers to answer calls and texts to the 24/7 care line, support patients after discharge, build detailed care plans, address gaps in care, and perform other patient-facing APCM services. 

The billing provider offers remote, general supervision of the services, and practice staff are closely involved in responding to clinical notifications and approving patients for the program. Though we can assist in documentation and preparing claims for billing, the billing practitioner's office must ultimately be the one to submit the final claim to CMS for reimbursement. 

Whether you choose to collaborate with a third-party provider like ChartSpan or provide APCM in-house, you will need to ensure you have enough staff and resources to offer all APCM service requirements. 

APCM Service Requirements

Advanced Primary Care Management differs from other care management programs, like Chronic Care Management or Principal Care Management, because it does not have time requirements. Practices can bill for APCM when they offer an enrolled patient the program’s required service capabilities, whether or not the patient uses them that month.

APCM’s remote, flexible preventative care is designed to empower patients and help them self-manage their conditions in between appointments. Under APCM, clinicians can adjust the services provided based on patients’ needs, not on trying to meet time requirements. 

The required service elements for APCM are:

• Patient consent before beginning APCM services
• An initiating visit for new patients. Patients seen within the past three years don’t need an initiating visit
• 24/7 access to care
• Comprehensive care management, including systemic need assessments, system-based approaches to preventive services, and medication reconciliation and management
• An electronic, patient-centered care plan
• Follow-up for patients within 7 days of their discharge from the hospital or emergency department
• Coordination of practitioner, home, and community-based care, in conjunction with provider
• Asynchronous, digital communication options, such as text, email, or patient portal
• Patient population-level management, including identification of gaps in care and risk stratification 
• Measure and report performance through the Value in Primary Care MIPS Value Pathway (MVP), an ACO, or an Advanced Alternative Payment Model

An experienced care management provider, such as ChartSpan, can help you set up each of these service elements, so you can ensure your patients receive the full benefits of Advanced Primary Care Management and your practice receives reimbursement when billing APCM codes. 

Reimbursement Rates for APCM Codes

Because APCM has three different levels for patients, it also has three different billing codes, with different reimbursement rates for each.* 

CPT code G0556

The national average reimbursement rate for CPT Code G0556, the code for patients with one or no chronic conditions, is $15 per patient, per month. The actual reimbursement amount will vary by state. 

CPT Code G0557

The national average reimbursement rate for CPT Code G0557, the code for patients with two or more chronic conditions, is $50 per patient, per month. The actual reimbursement amount will vary by state. 

CPT Code G0558

The national average reimbursement rate for CPT Code G0558, the code for patients with two or more chronic conditions who are also Qualified Medicare Beneficiaries, is $110 per patient, per month. The actual reimbursement amount will vary by state.

*The actual reimbursement amount will vary by geographic region. Check the Physician Fee Schedule for the latest information. Results may vary by provider.

APCM Billing Guidelines

To submit an APCM reimbursement claim to CMS, you will need a few critical pieces of information: 

1. The correct CPT code for the patient’s level
   1. G0556, G0557, G0558
2. The place of service
   1. This will be the same as for E&M encounters at your practice
3. The date of service
   1. For APCM, the last calendar day of the month
4. The National Provider Identifier (NPI) number
   1. This should be the provider who offers general supervision for the patient’s Advanced Primary Care Management program and serves as their focal point of care

It’s also important to remember that your Level 1 and 2 patients may have a copay that you are responsible for collecting. Level 3 patients will never have a copay. 

While your care management partner cannot submit your claims for you, they can help with documentation and setting up the correct claims, so you can review them, approve them, and submit them to CMS. This allows you to quickly receive reimbursement for your APCM claims. 

Simplify APCM Billing with a Full-Service Program 

When you partner with ChartSpan for Advanced Primary Care Management, we will create lists of patients eligible for the program, send those lists to you for review and approval, and ask for consent from eligible patients. If that patient provides consent, we will collaborate with your practice to offer the full range of care management services the program requires. 
We’ll also assemble the required documentation, identify the correct CPT codes, and submit the claims to your practice, so you can review, approve and submit them. If you’d like to learn more about APCM, APCM billing, or how ChartSpan can help you launch an APCM program, check out our complete guide to APCM.