2026 Billing Workflow Matrix
APCM + Behavioral Health + RPM/RTM
Quick reference for practice leaders and billers. Use this table at month-end before claims go out. Sources: CMS APCM page, CY-2026 PFS Final Rule Fact Sheet, MLN Telehealth & RPM.
| Scenario | Allowed? | Codes Involved | Evidence Required | Pre-Claim “Gotchas” |
|---|---|---|---|---|
| 1. APCM alone | Yes |
APCM base: G0556 / G0557 / G0558 |
• Consent & initiating-visit logic documented • 24/7 access & continuity with designated clinician/team • Comprehensive care plan updated this month (problems/goals, meds, transitions, population-management) |
• Only one APCM base per patient per month • Make sure APCM note can stand alone if audited |
| 2. APCM + BH add-on | Yes (with conditions) |
APCM base: G0556 / 57 / 58 BH add-on: G0568 / G0569 / G0570 |
• Same practitioner bills APCM and BH add-on in the same month • CoCM/BHI-comparable activities documented (screenings, care-manager notes, case review, outcomes) • BH work clearly tied to this APCM month |
• Reject if BH add-on present without APCM base that month • Reject if practitioners differ between APCM and BH add-on • Don’t also bill legacy CoCM/BHI for the same patient/month |
| 3. APCM + RPM | Yes (parallel) |
APCM base: G0556 / 57 / 58 RPM: 16-day codes (e.g., 99454) and/or new 2-15 day codes; mgmt codes (20+ min and/or 10-min codes) |
• APCM criteria met as in Scenario 1 • RPM medical necessity documented (dx + monitoring rationale) • Correct device-day bucket (2–15 vs 16–30) and mgmt-time bucket (10–19 vs 20+) • RPM evidence (days/time/actions) separate from APCM note |
• Enforce one RPM billing practitioner per pt / 30-day period • Don’t reuse APCM care-coordination time as RPM mgmt time • Make sure chosen RPM CPT matches documented days/time |
| 4. APCM + RTM | Yes (parallel) |
APCM base: G0556 / 57 / 58 RTM: Device + mgmt codes (e.g., 98975/77 and 10- / 20-min RTM mgmt codes) |
• APCM evidence as above • RTM medical necessity for therapeutic, non-physiologic data (pain, function, adherence) • RTM days/time consistent with chosen RTM CPT |
• Do not bill RTM and RPM together • Keep RTM evidence distinct from APCM note • Check supervision and incident-to rules for RTM team members |
| 5. APCM + BH add-on + RPM | Yes (highest complexity) |
APCM base: G0556 / 57 / 58 BH add-on: G0568 / 69 / 70 RPM: Appropriate device + mgmt codes |
• All APCM requirements satisfied • BH add-on work documented as in Scenario 2 • RPM evidence as in Scenario 3 • All three streams (APCM, BH, RPM) clearly separated in documentation |
• Same-practitioner rule for APCM + BH enforced • RPM practitioner exclusivity enforced • Double-counting guard: no APCM/BH time reused for RPM • If short-window RPM codes used, ensure correct CPT choice |
| 6. RPM / RTM only (no APCM) |
Yes |
RPM: Device + mgmt CPT RTM: Device + mgmt CPT |
• Established-patient + medical-necessity documentation • Device assignment, day counts, mgmt time, and actions documented • If RTM, therapy-oriented, self-reported data stream in place |
• One RPM practitioner per 30 days • No RPM + RTM pairing • Make sure you’re not also trying to bill APCM/BH for the same “work” |
| 7. BH add-on without APCM (or different practitioner) |
No |
BH add-on: G0568 / 69 / 70 APCM base missing or different practitioner |
• BH work documented but APCM base absent that month, or • BH add-on billed by a different practitioner than APCM |
• Treat as high-risk / do-not-bill scenario • Correct by adding APCM base (if criteria met) under same practitioner, or drop BH add-on • Validator should hard-fail this configuration |
This matrix is a planning aid. Always confirm current CMS/MLN guidance and your MAC’s edits before billing.