APCM Requirements: The CMS Checklist, Element by Element

Advanced Primary Care Management pays a monthly amount per patient with no minimum time to log. That is the part everyone remembers. The part that decides whether a practice can bill it with confidence is the list of service elements CMS expects to be in place.

This is that list, element by element, with what each one looks like in day-to-day practice. If you are new to APCM, our plain-language guide covers the basics first.

Who can bill, and for whom

Physicians, nurse practitioners, physician assistants and clinical nurse specialists can bill APCM, as long as the practice is the patient’s primary care home and the focal point for coordinating their care. The CMS program page has the full description.

CMS is explicit in its APCM FAQ that any patient is eligible as long as they consent. The patient’s conditions only decide which code you bill: G0556, G0557 or G0558.

The checklist: what CMS expects in place

Across CMS’s materials and the AAFP summary, these are the core elements.

1. 24/7 access and continuity

Patients need a way to reach the care team for urgent needs at any hour, and continuity with a designated member of the care team. In practice, that means a documented after-hours path and a named care team for each enrolled patient.

2. A comprehensive, electronic care plan

Each enrolled patient needs a care plan maintained electronically and available to the care team. It should reflect the patient’s conditions, goals and the services the practice is providing.

3. Coordination of care transitions

When a patient moves between settings, such as a hospital discharge or an ED visit, the practice coordinates the transition. Following up on discharge summaries and specialist notes is part of the work.

4. Coordination with community and specialist care

The practice coordinates with home and community-based providers, specialists and caregivers, so the care plan reflects what is happening outside the clinic too.

5. Population health management

The practice manages its panel as a population, including risk stratification, so the patients who need the most attention get it first.

6. Enhanced communication

Patients can reach the care team through channels beyond the office visit, such as a patient portal, secure messaging and remote check-ins.

7. Performance measurement

This element has teeth. MIPS-eligible clinicians are expected to report through the Value in Primary Care MIPS Value Pathway, or to participate in an approved model such as the Medicare Shared Savings Program or ACO REACH. If your practice is in an ACO, participation generally covers it.

Consent and the initiating visit

• Consent. Written or verbal, documented in the patient’s record before you bill.
• Initiating visit. Required for new patients, but waived if the patient has been seen in the last three years, or has received APCM, CCM or PCM in the past year.
• Cost sharing. Standard Part B cost sharing applies. Qualified Medicare Beneficiaries cannot be billed for it, which is one reason dual-eligible patients are an easy place to start.

The rules that trip practices up

• One program per patient per month. APCM, CCM and TCM cannot be billed by the same clinician for the same patient in the same month.
• No time log, but not no record. There is no minimum monthly time threshold. The documentation has to show the service elements were in place and that care actually happened.
• It has to be monthly. APCM revenue is recurring only if the work is recurring.

If you are a health center

FQHCs and RHCs can bill APCM, paid separately at the non-facility Physician Fee Schedule rate and on top of the PPS rate for the visit. Our APCM guide for health centers covers the PPS question in detail.

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Frequently asked questions

Is there a minimum time requirement for APCM?

No. APCM has no minimum monthly time threshold, which is the biggest difference from chronic care management.

Does APCM require patient consent?

Yes. Consent can be written or verbal, and it has to be documented in the patient’s record.

Is an initiating visit required for APCM?

Only for new patients. It is waived if the patient has been seen in the last three years, or has received APCM, CCM or PCM in the past year.

Can APCM and CCM be billed in the same month?

No. The same clinician cannot bill APCM, CCM and TCM for the same patient in the same month.

At Droxi, we built Unlock to take on the operational side of APCM, so a practice can run the program without adding headcount. If you want to see what your Medicare panel could support, we are happy to run the numbers with you.