APCM G0556–G0558 Monthly Bundle Rules

6.1 What APCM Is

CMS states APCM “combine[s] elements of several existing care management and communication technology-based services.” AAFP expands the bundled set to include CCM, PCM, TCM, interprofessional consultation codes, online digital E/M codes, and specific HCPCS virtual check-in/remote evaluation codes.

6.2 Frequency and Unit of Service

• CMS: APCM may be billed once per patient per calendar month.
• AAFP: Monthly only; one clinician reports APCM per patient per month.

Treat the calendar month as the ledger. Concurrency mistakes happen when programs use rolling 30-day windows instead of patient-month decisions.

6.3 The Three Code Levels

• G0556: Base APCM requirements with a primary-care focal clinician directing clinical staff.
• G0557: G0556 requirements plus two or more chronic conditions meeting CMS’s duration/risk standard.
• G0558: G0556 requirements plus QMB status and the same chronic condition standard.

6.4 APCM Is Non-Time-Based

APCM removes minute thresholds. Documentation shifts to program elements—consent, access, care planning, transitions, population management, performance measurement—rather than time logs.

6.5 What CMS Requires

• Patient consent (disclosing one-provider-per-month and cost-sharing expectations).
• Initiating visit logic with CMS exceptions; AWV may qualify in some cases.
• 24/7 access and continuity processes.
• Electronic, shareable care plan.
• Care transitions coordination with timely follow-up (within 7 days when clinically indicated).
• Population-level management and performance measurement (reporting begins in 2026 for CY 2025 performance).
• Auxiliary personnel may furnish services incident to under general supervision.

• Month-to-month switches: CCM one month and APCM the next is allowed, but consent is separate for each program.
• Elements every month? Not required. You must maintain the ability to deliver all elements and complete them when clinically appropriate.
• Initiating visit: Required for “new” patients with CMS exceptions (seen in past 3 years or received another care management service in past year); AWV may qualify in some cases.

• Billing timing within month: APCM may be billed at any point during the calendar month; billing early can preclude CCM/TCM that month.
• Partial months: CMS does not create a partial-month APCM concept. If you cannot support APCM elements for the patient-month, do not bill APCM.
• Concurrency with other programs: Co-occurring services (e.g., BHI/CoCM) must meet independent requirements and avoid double-counting effort; payer edits may vary.

• Convert APCM from “a billing code” to “a monthly operating model.”
• Create a patient-month exclusivity gate so APCM suppresses overlapping CCM/PCM/TCM and bundled digital communication codes.
• Standardize tiering logic on CMS chronic-condition criteria for G0557/G0558, not problem-list length.
• Treat consent as a first-class artifact with one-provider-per-month and cost-sharing disclosure.

• Keep the care plan electronic, maintainable, and shared with patient/caregiver.
• Implement discharge follow-up workflows that meet the “within 7 days when clinically indicated” expectation.
• Build QMB detection into intake and billing to prevent prohibited cost-sharing for G0558.
• Produce a month-end APCM note summarizing interactions, care plan updates, coordination events, and transition follow-up.

• APCM moves primary care toward larger units of service with capability requirements, informed by CPC+ and Primary Care First models.
• Design choices emphasize program-level accountability: non-time-based, electronic care plans, transitions, population management, and performance measurement.
• CY 2026 adds behavioral health add-ons to APCM rather than encouraging parallel monthly stacks, signaling CMS’s trajectory toward bundled primary care.