RPM Manual
The practical 2026 guide to device rules, day thresholds, management time, and audit defensibility for Remote Patient Monitoring.
Read the RPM Guide →Advanced Primary Care Management (APCM)
A practical guide to the new 2025 Medicare primary-care bundle
See the FairPath APCM ProgramManually modeling G0556–G0558 plus the G0568–G0570 add-ons invites billing mistakes.
Calculate your stable revenue with the APCM Revenue Calculator.
1. What APCM Is
Advanced Primary Care Management (APCM) is a new family of care-management services under the Medicare Physician Fee Schedule that pays a monthly, non–time-based fee for “advanced primary care” across your Medicare panel. Instead of stacking multiple time-based care-management and communication-technology codes, you report one APCM code per patient per calendar month when requirements are met.[1]
APCM is explicitly defined as a bundle that combines work you already do between visits--chronic/principal care management, transitional care, and communication-technology services (virtual check-ins, remote evaluation of prerecorded information, interprofessional consults)--into a single monthly payment.[1]
Medicare’s public explainer for beneficiaries describes APCM providers as offering 24/7 access, a personalized care plan, chronic care management, care coordination, transitional care, and medication management throughout the month.[2]
2. Who Can Bill APCM (and for Whom)
2.1 Eligible billers
- Who: Physicians and non-physician practitioners (NP, PA, CNS, CNM) who are responsible for the patient’s ongoing primary care and act as the continuing focal point for all needed services.[1]
- How services are furnished: Clinical staff and auxiliary personnel may furnish most APCM elements incident to under general supervision of the billing practitioner, using the practice’s care-management infrastructure.[1]
-
Settings: Office-based practices, RHCs, and FQHCs can all participate.
RHC/FQHC Alert: As of Oct 1, 2025, the G0511 bundle was discontinued. RHCs and FQHCs must now use the specific APCM G-codes (G0556–G0558) or individual care management codes to be reimbursed at the national non-facility PFS rate.
2.2 Eligible patients
APCM is designed to be broadly applicable across your Medicare primary-care panel. Patients are assigned to one of three risk tiers based on chronic-illness burden and social risk:
- G0556: Patients with one or no chronic conditions under the care of a practitioner responsible for all primary care.[1]
- G0557: Patients with ≥2 chronic conditions expected to last ≥12 months (or until death) and posing significant risk of death, acute exacerbation/decompensation, or functional decline.[1]
- G0558: Patients who meet G0557 criteria and are also Qualified Medicare Beneficiaries (QMBs) or in a similar high social-risk category.[1]
In practice, that means nearly every Medicare primary-care patient can be placed in an APCM tier: prevention/early-management patients in G0556, complex chronic patients in G0557, and high-risk QMBs in G0558.
3. Codes & Payment
APCM is reported once per patient per calendar month. You choose one of the APCM codes (G0556–G0558) according to patient complexity and chronic-condition count; only one practitioner can bill APCM for a given patient and month.[1]
G0556
Advanced primary care management services for a patient with no more than one chronic condition, furnished by clinical staff under the practitioner who is responsible for all primary care and serves as the focal point for all needed health services, per calendar month.[1]
G0557
Advanced primary care management for a patient with ≥2 chronic conditions (lasting ≥12 months or until death, with significant risk of decompensation or decline), furnished by clinical staff under the responsible practitioner. Includes all G0556 service expectations.[1]
G0558
Same clinical criteria as G0557, but for a Qualified Medicare Beneficiary (QMB) or similar high social-risk patient; state programs cover applicable cost-sharing for QMBs. Includes all G0556 service expectations.[1]
Payment amounts: APCM payments are based on RVUs, the annual conversion factor, and geographic adjustments. Rates vary by MAC and locality.
Use the official PFS Look-Up Tool to find current allowed amounts for G0556–G0558 in your locality and to calculate patient coinsurance.[3]
Behavioral Health Integration Add-ons (2026+)
Effective Jan 1, 2026, these add-on codes allow you to integrate behavioral health without the strict minute-counting of traditional CoCM/BHI codes. These are billed in addition to the APCM base code.
| Code | Service | The "FairPath" Difference |
|---|---|---|
| G0568 | CoCM Initial Month | Mirrors CPT 99492 but removes the 70-minute requirement. |
| G0569 | CoCM Subsequent | Mirrors CPT 99493 but removes the 60-minute requirement. |
| G0570 | General BHI | Mirrors CPT 99484 but removes the 20-minute requirement. |
4. The 13 APCM Service Elements (What You Need Available)
CMS defines APCM through a set of 13 service elements. You don’t need to provide every element to every APCM patient every month, but your practice must be able to furnish them and document when they are used.[1]
- Consent & choice of provider: Explain APCM, that only one practitioner may bill APCM per month, that the patient can stop at any time, and that Part B cost-sharing may apply (except for QMBs). Document consent (verbal or written) once and keep it on file.[1]
- Initiating visit (when required): For new patients, those not seen in ≥3 years, or those without a recent care-management service, an in-person visit (E/M or AWV) by the responsible practitioner is required as the APCM anchor.[1]
- 24/7 access: After-hours urgent access to a care-team member with real-time chart access, via phone, portal, or virtual visit, so patients can reach the practice beyond normal business hours.[2]
- Continuity & focal point: A designated practitioner and team who act as the patient’s ongoing focal point for all needed care, not a rotating vendor call center.[1]
- Flexible, patient-centered care delivery: Ability to provide care via extended hours, home visits, or other modalities when appropriate, so primary care is genuinely accessible for the panel you serve.[1]
- Comprehensive care management: Structured needs assessments (medical, functional, psychosocial), preventive-service follow-through, and ongoing medication reconciliation and management.[1]
- Electronic, patient-centered care plan: A living care plan in CEHRT that is accessible inside and outside the practice, routinely updated, and shared with the patient/caregiver (portal or copy).[1]
-
Care transitions: Timely information exchange and follow-up within 7 days of hospital/ED/SNF discharge or other major transitions,
including documentation of outreach and reconciliation steps.[1]
Compliance Stop: If a patient requires full Transitional Care Management (CPT 99495/99496) regarding medical decision making and a face-to-face visit, you must pause APCM billing for that month. You cannot bill both in the same calendar month.
- Coordination with other clinicians & community services: Ongoing communication and documentation with specialists, home health, and community/social-service organizations as clinically appropriate.[1]
- Enhanced communication options: Asynchronous tools beyond office visits--secure messaging/portal/email, remote review of prerecorded information, interprofessional e-consults, e-visits, and virtual check-ins.[1]
- Population analytics: Use of panel-level data to identify gaps in care (e.g., overdue screenings, uncontrolled BP/A1c) and track utilization patterns across APCM patients.[1]
- Risk stratification: A structured method to segment the panel into risk tiers aligned to G0556/57/58 so higher-risk patients receive more intensive management and follow-up.[1]
- Performance measurement & CEHRT-based reporting: Tracking of primary-care quality, total cost of care, and use of CEHRT, with reporting through the Value in Primary Care MVP (for MIPS-eligible clinicians) or via an ACO/other qualifying model.[1]
5. The 7 Deadly Audit Risks of APCM
APCM is simpler than CCM, but it is not "free money." The OIG has already flagged care management for overpayments. Avoid these specific failure modes found in recent audits.
1. The "Phantom Bill"
The Risk: Billing G0556 without documenting any of the 13 elements for that month.
The Rule: While there are no minute minimums, "you cannot bill for doing nothing." If a patient had no needs and you performed no proactive work (reviewing care plan, analytics check, outreach), do not bill.
2. The 7-Day Trap
The Risk: A patient has an ER visit, but your chart shows no contact within 7 days.
The Rule: Missing the 7-day post-discharge window is a binary fail for APCM compliance in that month. Auditors specifically look for ADT alerts followed by documented outreach.
3. The QMB Mismatch
The Risk: Billing G0558 (Tier 3) for a patient who is complex but not a Qualified Medicare Beneficiary.
The Rule: G0558 is strictly for QMBs (low-income). Use your MAC eligibility file to verify QMB status monthly. Billing Tier 3 for a non-QMB is considered upcoding.
4. The "Condition of Payment" Trap
The Risk: Billing APCM but failing to register for the "Value in Primary Care" MVP.
The Rule: For MIPS-eligible clinicians not in an ACO, reporting the MVP is a mandatory condition of payment starting in 2026. Failure to report may lead to recoupment.
6. Interaction Matrix: What Can You Bill with APCM?
Use this "Go/No-Go" matrix to configure your billing software edits.
| Service Type | Can Bill? | Notes & Constraints |
|---|---|---|
| RPM / RTM | YES | Allowed if services are non-duplicative (e.g., device data review vs. care coordination). |
| CCM / PCM | NO | APCM is a bundle that replaces CCM/PCM for that month. |
| TCM (99495/6) | NO | Correction: CMS considers APCM duplicative of TCM. Pause APCM for the TCM month. |
| ACO (MSSP) | YES | You can bill APCM FFS codes. Counts as expenditure but satisfies quality reporting. |
| ACO (REACH) | DEPENDS | NO if Capitated. YES if FFS/Partial Capitation. |
| Home Health Oversight (G0181) | NO | Cannot bill concurrently with APCM. |
7. APCM vs CCM vs RPM
7.1 APCM vs time-based CCM/PCM
Traditional Chronic Care Management (CCM) and Principal Care Management (PCM) codes are time-based and require tracking a minimum number of minutes per month (e.g., ≥20 minutes for non-complex CCM). Documentation and billing are centered on cumulative time thresholds.[5]
APCM is not time-based. Instead of hours-and-minutes accounting, CMS defines a set of structural expectations (the 13 elements) and risk tiers (G0556–G0558). You bill one APCM code per month when those structural requirements and risk-appropriate services are met.[1]
Importantly, CCM codes remain available. APCM is best thought of as a broader, advanced primary-care bundle that combines elements of CCM, PCM, TCM, and communication-technology services into a single payment, rather than as a formal repeal of CCM.[1]
7.2 APCM vs RPM/RTM
Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) codes pay for device supply and physiologic/therapeutic data review, with their own requirements (e.g., 16 days of data per 30-day period for RPM device supply).[5]
APCM does not include device supply or physiologic monitoring in its bundle. In most settings, APCM can coexist with RPM/RTM for the same patient and month when services are clinically appropriate and not duplicative. Practices should rely on PFS indicators, NCCI edits, and MAC guidance to confirm allowed combinations for their jurisdiction.[3]
8. Implementation Blueprint
APCM is conceptually simple but operationally demanding. You are moving from a handful of ad hoc codes to a program-level commitment that touches panel management, access, documentation, billing, and quality reporting.
8.1 Standing up APCM without dedicated software
- Assign ownership: Designate a clinical champion (physician/NP), RCM lead, and program manager (RN/MA/office manager) responsible for APCM policies, code selection, and audits.
- Panel & tiering: Extract your active Medicare panel and segment patients into provisional G0556/57/58 tiers based on chronic conditions and QMB status.
- Consent & enrollment: Build a consent script that meets CMS expectations, and configure your EHR so APCM consent status, date, staff, and script version are captured discretely.
- Access & continuity: Formalize your on-call rota with documented real-time EHR access; decide how continuity is expressed (named RN/MA per cohort, reassignment rules, etc.).
- Care-plan, transitions, and communication templates: Standardize care-plan content, transitions-of-care templates (with ≤7-day follow-up), and portal/secure messaging workflows.
- Population analytics & risk tools: Even if spreadsheet-based, establish condition registries, risk tiers, and gap lists (e.g., BP, A1c, screenings) for APCM patients.
- Billing & quality cycle: At month end, review APCM-enrolled patients, confirm documentation for the 13 elements, assign G0556/57/58, and align the panel with your Value in Primary Care MVP or ACO reporting plan.[6]
- Internal audits: Quarterly, sample APCM charts to verify consent, care-plan currency, transitions documentation, after-hours logs, risk-tier logic, and quality measure capture.
8.2 Using a platform like FairPath
APCM was designed to be run by the practice rather than by a third-party call center, but running it on spreadsheets and generic EHR templates quickly becomes brittle. A dedicated platform can automate panel identification, enforce “evidence-by-design” workflows aligned with the 13 elements, and generate both the monthly APCM claim file and the quality/MVP exports you need to stay compliant.
9. Frequently Asked Questions
1
Does APCM replace CCM?
No. CMS created APCM to bundle and simplify advanced primary care, combining elements of CCM, PCM, TCM, and certain communication-technology services. CCM codes remain available. APCM is billed once per calendar month when its structural requirements are met.[1]
2
Can I bill APCM and CCM/PCM/TCM in the same month?
Generally, No. You cannot bill CCM, PCM, or TCM (Transitional Care Management) in the same month as APCM. CMS views these as duplicative. If a patient requires TCM (face-to-face visit + moderate/high decision making within 14 days of discharge), bill TCM for that month and pause APCM.
3
Can I bill APCM and RPM/RTM in the same month?
APCM does not include device supply or physiologic monitoring, so RPM/RTM codes generally remain separately billable for the same patient and month when services are clinically appropriate and non-duplicative. The key is to avoid double-counting the same work under both APCM and RPM/RTM and to follow PFS/NCCI indicators and MAC policies for your region.[3]
4
Do I have to participate in the Value in Primary Care MVP to bill APCM?
Yes. For MIPS-eligible clinicians not in an ACO, reporting the "Value in Primary Care" MVP is a condition of payment starting in 2026. It is not optional; failure to report can jeopardize your APCM revenue during an audit.
5
What is the patient cost-sharing for APCM?
APCM is a Part B service. After the Part B deductible, most beneficiaries pay 20% coinsurance of the Medicare-approved amount. Qualified Medicare Beneficiaries (QMBs) do not pay cost-sharing; state programs or other payers cover their coinsurance and deductible. Your consent process should explain both the general cost-sharing and the QMB exception.[2]
6
Where do I find the exact dollar amount for my locality?
Use the official PFS Look-Up Tool, search for G0556–G0558, and select your MAC and locality. The tool will show current allowed amounts and patient coinsurance obligations.[3]
Ready to see what APCM could mean for your practice?
Use the FairPath APCM calculator and readiness tools to estimate your panel’s APCM revenue and identify the policies, workflows, and documentation you still need to put in place.
Explore the FairPath APCM Program