Advanced Primary Care Management: Enhancing Patient Care

By Lusine Hambardzumyan and Arman Hovhannisyan, Billing Department, WCH

Advanced Primary Care Management (APCM) represents a transformative approach developed by CMS to deliver comprehensive, patient-centered care addressing both physical and behavioral health needs. By consolidating multiple care management services into a unified framework with streamlined billing, APCM enables healthcare providers to manage complex patient needs more effectively while reducing administrative burden.

Understanding APCM: Structure and Core Components

APCM integrates several existing care management services into a cohesive model: Principal Care Management (PCM) for patients with single complex chronic conditions, Transitional Care Management (TCM) for care transitions, and Chronic Care Management (CCM) for multiple chronic conditions. The primary advantage lies in bundling various services into a single monthly payment, eliminating separate billing for each service and detailed time tracking requirements.

APCM Code Structure

Core APCM Codes:

G0556 – Clinical staff-provided APCM services where a physician or qualified healthcare professional directs clinical staff and serves as the continuing focal point for all needed healthcare services

G0557 – For patients with two or more chronic conditions expected to last at least 12 months or until death, placing the patient at significant risk of death, acute exacerbation, decompensation, or functional decline

G0558 – For qualified Medicare beneficiaries meeting the same criteria as G0557, including all requirements for G0556

Behavioral Health Integration Add-On Codes (Effective January 1, 2026)

Three new Level 2 add-on codes facilitate billing for behavioral health integration services, particularly benefiting federally qualified health centers (FQHCs) and rural health clinics (RHCs):

G0568 – Initial Psychiatric Collaborative Care Management (based on CPT 99492): Estimated reimbursement $17.96

G0569 – Subsequent Psychiatric Collaborative Care Management (based on CPT 99493): Estimated reimbursement $26.30

G0570 – Care Management Services for General Behavioral Health Condition (based on CPT 99484): Estimated reimbursement $24.38

These codes remove prior time-based documentation requirements, allowing auxiliary personnel to provide services under the general supervision of the billing practitioner.

Essential Requirements for APCM Implementation

Critical Foundation Elements:

Patient Consent: Providers must inform patients of eligibility, cost-sharing, discontinuation rights, and obtain verbal or written documented consent

Initiating Visit: This is a critical requirement – New patients require an initial visit unless they have been seen within the past three years or are currently receiving care management services (CCM, PCM). This visit establishes the foundation for the patient-provider relationship and comprehensive care plan development

24/7 Access and Continuity: Patients must have real-time access to their care team and medical information at all times

Comprehensive Care Management: A proactive, organized approach focusing on prevention and understanding individual health needs

Patient-Centered Care Plan: Personalized care plans developed collaboratively with patients, addressing unique needs, and regularly updated

Care Transition Coordination: Ensuring smooth transitions between different settings and providers, including hospital communication and post-discharge follow-ups

Home and Community-Based Coordination: Extending care outside traditional clinical settings, coordinating home health, social services, and community resources

Enhanced Communication Methods: Utilizing modern technology, including patient portals, secure messaging, telehealth platforms, and remote monitoring

Population Health Management: Managing defined patient populations through risk stratification and targeted interventions

Performance Measurement: Tracking and reporting clinical quality measures, patient satisfaction, healthcare utilization, and engagement levels

Provider Eligibility and Billing Requirements

Eligible Providers (Starting January 1, 2025):

Physicians (MDs and DOs)

Non-Physician Practitioners: nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives

Billing Criteria

Providers must be responsible for all primary care services, serve as the central coordination point for healthcare services, obtain documented patient consent, and practice in primary care specialties (general internal medicine, family medicine, pediatrics, geriatric medicine).

Billing Frequency and Documentation

APCM services can be billed once per patient per calendar month. Unlike traditional care management services, APCM does not require time-based documentation. Key billing rules:

Only one clinician can bill for APCM per patient per month

No overlapping care management services (CCM, PCM, TCM) for the same patient in the same month

Focus on ensuring capacity to provide required elements when clinically appropriate, not delivering every service element monthly

Services can be billed at month-end when all services are completed

Team-Based Care and Incident-To Provision

APCM services can be provided by auxiliary personnel (nurses, care managers, social workers, trained staff) under the general supervision of the billing provider. The provider does not need physical presence but must be available for oversight and remains responsible for the care plan. Auxiliary personnel must meet state licensure requirements and cannot be excluded from federally funded healthcare programs.

This team-based approach improves patient access, reduces provider burden, and simplifies documentation while enhancing care delivery efficiency.

Behavioral Health Integration: Critical Role and Implementation

Why BHI Matters in Primary Care

Behavioral health conditions frequently coexist with chronic physical conditions, creating complex care needs. Patients with both experience higher healthcare utilization, increased hospitalization risk, poorer disease management outcomes, and reduced quality of life. Integrating behavioral health into primary care addresses these challenges by providing comprehensive treatment in a single setting, reducing stigma, improving coordination, and achieving better overall outcomes.

The Psychiatric Collaborative Care Model

Supported by codes G0568 and G0569, this model involves:

Care Manager: A designated team member providing regular patient follow-up, monitoring treatment response, supporting self-management, and facilitating communication between primary care and psychiatric consultant

Psychiatric Consultant: A psychiatrist or psychiatric nurse practitioner providing regular consultation, reviewing challenging cases, and making treatment recommendations

Primary Care Provider: The physician or NPP remaining responsible for overall care, implementing recommendations, prescribing medications, and coordinating services

General Behavioral Health Condition Management (G0570)

Addresses conditions not requiring full psychiatric collaborative care, including mild to moderate depression, anxiety disorders, adjustment disorders, and stress-related conditions. Services include behavioral health screening, brief counseling, care coordination with specialists, status monitoring, and treatment adherence support.

Service Delivery Settings and Telehealth Flexibility

Approved Settings

According to the Calendar Year 2026 Physician Fee Schedule Final Rule, APCM and BHI services can be delivered in physician offices, hospital outpatient departments, ambulatory surgical centers, skilled nursing facilities, patient homes, federally qualified health centers, and rural health clinics. Starting January 1, 2026, APCM and BHI services are explicitly permitted in RHCs and FQHCs, significantly expanding access in community-based safety net settings.

Remote and Telehealth Capabilities

The 2026 Final Rule provides substantial flexibility for remote service delivery:

Virtual Direct Supervision: Supervising physicians can provide direct supervision via real-time audio and visual telecommunications instead of physical presence

Incident-To Services: Virtual supervision applies to auxiliary personnel services, enabling care managers and behavioral health coordinators to deliver services under remote supervision

RHC and FQHC Remote Supervision: Extended virtual supervision enables these facilities to provide services remotely when appropriate, particularly important for rural or underserved areas

Telehealth Considerations: Providers must verify specific codes are eligible for telehealth under Medicare. Not all care coordination services qualify as telehealth even if provided remotely. High-risk procedures still require in-person supervision, though this rarely applies to APCM services.

Practical Implications

Practices can adopt team-based care models where auxiliary staff handle key care aspects with remote physician supervision, reducing provider burden while maintaining compliance. This approach particularly benefits underserved populations in rural areas, eliminating travel requirements and improving access to essential behavioral health services.

Financial Considerations and Reimbursement

Medicare Reimbursement Rates (2025-2026)

APCM Base Codes:

G0556 (Level I): $15.20 per patient per month

G0557 (Level II): $48.84 per patient per month

G0558 (Level III): $107.07 per patient per month

BHI Add-On Codes (2026):

G0568: $17.96

G0569: $26.30

G0570: $24.38

Commercial Reimbursement Considerations

Commercial reimbursement rates are typically not publicly available. Providers must negotiate contracts with individual payers, which can be time-consuming with rates varying widely based on payer guidelines, network status, and market conditions.

Key strategies:

Directly contact insurers to determine reimbursement rates and coverage policies

Utilize benchmarking resources from organizations like the National Association of Community Health Centers (NACHC)

Clarify documentation requirements during contract negotiations, as commercial payers may have different requirements than Medicare

Common Audit Risks and Compliance

Key Audit Risk Areas:

Lack of Patient Consent: Failing to obtain and properly document consent is the most common audit risk. Consent must be clearly documented in medical records, including what was explained and the patient understanding of discontinuation rights

Missing Initiating Visit: Failure to document the required initial visit for new APCM patients who haven’t been seen within three years or aren’t receiving other care management services

Billing Without Primary Care Responsibility: Billing when not serving as the patient’s primary care provider. Providers must document their role as the primary care provider and central coordinator

Overlapping Services: Billing multiple care management codes in the same month. Providers must track which services are billed monthly

Insufficient Documentation: While time-based documentation is not required, providers must document services provided, care plan development and updates, care coordination activities, patient progress, and communications

Best Practices for Compliance

Develop standard operating procedures, implement comprehensive staff training, utilize technology solutions supporting APCM workflows, conduct regular internal audits, maintain clear documentation, track billing carefully to ensure only one care management code per patient per month, and monitor regulatory updates.

Implementation Strategies

Readiness Assessment
Evaluate infrastructure (EHR capabilities, care management platforms, telehealth technology), staffing (qualified care managers, behavioral health specialists, support staff), patient population (number eligible, prevalence of behavioral health conditions, geographic distribution), and financial considerations (startup costs, expected reimbursement, ROI timeline).

Workflow Development
Design workflows for patient identification and enrollment (including scheduling and initiating visits), care team structure with defined roles and communication protocols, care plan development and management with behavioral health integration, communication and coordination systems, and documentation and billing procedures with quality assurance.

Technology Infrastructure
Implement electronic health records with care management modules and population health tools, telehealth platforms with video conferencing and secure messaging, care management platforms with patient tracking and task management, and population health tools for risk stratification and registry management.

Advanced Primary Care Management with integrated behavioral health services enables healthcare providers to deliver comprehensive, coordinated care more efficiently. The 2026 enhancements, including behavioral health integration add-on codes and expanded telehealth flexibility, particularly benefit rural and underserved populations. Successful implementation requires careful planning, adequate infrastructure, trained staff, and ongoing quality improvement commitment. Providers investing in robust APCM programs will be well-positioned to meet evolving patient needs while achieving financial sustainability through appropriate reimbursement.

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Sources

Centers for Medicare & Medicaid Services (CMS). Calendar Year 2026 Medicare Physician Fee Schedule (PFS) Final Rule. U.S. Department of Health and Human Services.

Centers for Medicare & Medicaid Services (CMS). Advanced Primary Care Management (APCM) Services — Medicare Learning Network (MLN).

Centers for Medicare & Medicaid Services (CMS). Behavioral Health Integration Services Fact Sheet.

Centers for Medicare & Medicaid Services (CMS). Telehealth Services Under Medicare — Policy Updates and Coverage Guidance.

National Association of Community Health Centers (NACHC). APCM and Care Management Implementation Resources for FQHCs.

Office of Inspector General (OIG), HHS. Compliance Program Guidance for Individual and Small Group Physician Practices.

American Psychiatric Association & AIMS Center (University of Washington). The Collaborative Care Model: Evidence Base and Implementation Guidance.