Operational Strategy

The Incident To Pathway

How pharmacies can operationalize APCM using incident to rules without waiting for federal provider status

Operational strategy for pharmacy-led care management

Published: February 3, 2026

For Pharmacy Owners, Operations Leads

Compliance note: This resource is educational and does not constitute legal advice. Incident to billing, APCM participation, and any financial arrangement between a pharmacy and a billing practitioner should be reviewed for compliance with applicable federal and state requirements, including payer policies and program integrity expectations.

The Opportunity

The Barrier

Pharmacists deliver high-value clinical work, but Medicare billing is still tied to specific practitioner types.

The Bridge

The "incident to" benefit (42 CFR 410.26) allows designated care management services to be furnished under general supervision.

The Vehicle

Advanced Primary Care Management (APCM), a monthly bundle designed around clinical staff delivering services under direction.

Executive Summary

Many pharmacy owners have a reasonable frustration: pharmacists deliver high-value clinical work, but Medicare billing is still tied to specific practitioner types and billing structures. Congress may eventually expand pharmacist provider status, but your operating plan cannot depend on an uncertain timeline.

Medicare already has an established mechanism that can allow pharmacy staff to contribute to care management workflows today: the “incident to” benefit in 42 CFR 410.26. In general, incident to services require direct supervision. However, the regulation explicitly allows designated care management services to be furnished under general supervision when provided incident to the services of a billing physician or other practitioner. (Legal Information Institute)

Separately, CMS created Advanced Primary Care Management (APCM) as a monthly bundle starting January 1, 2025 using HCPCS codes G0556, G0557, and G0558. APCM is not time-based, is billed once per patient per month, and is designed around clinical staff delivering services under the direction of the responsible billing clinician. (CMS)

The practical strategy is not a loophole. It is an operating model: the billing practitioner bills APCM, the pharmacy supplies defined clinical operations through a compliant agreement, and documentation is engineered so the billed service is real, attributable, and defensible.

Section index

I. The real problem behind “provider status”
II. The incident to benefit in plain English
III. APCM is the billing vehicle that makes this practical
IV. The operating model: pharmacy as the clinical extension team
V. Contracting and compliance
VI. Documentation: the minimum viable “audit packet”
VII. Implementation roadmap
References

I. The real problem behind “provider status”

Two different questions get conflated:

Can pharmacists perform clinical care management work that improves outcomes?

Often yes, subject to state scope of practice and program design.

Can the pharmacy bill Medicare Part B directly for that work?

Often no, because Medicare Part B billing is tied to eligible billing practitioners and coverage rules.

The incident to benefit is one of the bridges between these realities, but only if you design it correctly and you do not double bill under Part D for the same work.

II. The incident to benefit in plain English

The core definition

Medicare Part B pays for services and supplies “incident to” a physician’s (or other practitioner’s) professional services only when specific conditions are met. Those conditions include that the services are furnished in a noninstitutional setting, are an integral though incidental part of the practitioner’s diagnosis or treatment, and meet the supervision and state law requirements. (Legal Information Institute)

The supervision rule that matters

The default supervision requirement is direct supervision. However, the regulation explicitly states: “Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner).” (Legal Information Institute)

What “general supervision” means operationally

General supervision means the supervising practitioner provides overall direction and control, but is not required to be physically present during performance of the service. The constraint is not physical proximity. The constraint is responsibility, clinical direction, documentation, and correct attribution under the billing practitioner. (Legal Information Institute)

Auxiliary personnel includes leased staff and contractors

The incident to regulation defines “auxiliary personnel” to include individuals acting under the supervision of a physician or other practitioner “regardless of whether the individual is an employee, leased employee, or independent contractor,” and the definition includes additional eligibility requirements such as not being excluded and meeting applicable state requirements. (eCFR)

Pharmacists fit within auxiliary personnel for incident to purposes

CMS explicitly addressed that pharmacists fall within the regulatory definition of auxiliary personnel under 410.26 and may provide services incident to the billing physician or NPP under the appropriate level of supervision, as long as payment for the services is not made under the Medicare Part D benefit. (CMS)

This last clause is not optional. It is the “Pharmacy Firewall” principle applied to incident to: you cannot use Part B to get paid for work that is already being paid under Part D.

III. APCM is the billing vehicle that makes this practical

APCM is designed to remove the minute-by-minute documentation burden of time-based care management codes and replace it with a monthly bundle reflecting essential elements of advanced primary care. CMS finalized new coding and payment for APCM effective January 1, 2025. (CMS)

Who can bill APCM

CMS states that starting January 1, 2025, APCM can be billed by a physician or non-physician practitioner (NPP) such as NP, PA, or CNS who is responsible for all the patient’s primary care services and serves as the focal point for all needed health care services, and who has obtained patient consent. (CMS)

How often APCM can be billed

CMS states APCM can be billed once per patient per calendar month. It is not time-based. (CMS)

The APCM code levels

CMS defines three APCM codes and their core differences: (CMS)

Code	Description
G0556	Clinical staff provide the APCM services, directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point.
G0557	Patient has two or more chronic conditions meeting duration and risk criteria, and the service includes all G0556 requirements.
G0558	Patient is a Qualified Medicare Beneficiary with two or more chronic conditions meeting the same duration and risk criteria, and the service includes all G0556 requirements.

Do not publish payment amounts as fixed values: APCM payment varies by locality and other factors. If you need precise numbers for your ROI model, use CMS PFS data sources and compute rates for your locality and setting. CMS does not present APCM payments on the APCM overview page itself, and blog tables are not authoritative. (CMS)

APCM requirements that matter for pharmacy operating partners

CMS lists a detailed set of billing requirements. For pharmacy-led execution, the high-impact requirements are the ones that force real operations rather than “paper care management.” (CMS)

Patient consent: You must get written or verbal consent and document it. Consent must inform the patient that only one provider can furnish and be paid for APCM during a calendar month, that the patient can stop services at any time, and that cost sharing may apply. Consent is required once and must be obtained before services start. (CMS)
Initiating visit rule for new patients: CMS requires an initiating visit for new patients, with exceptions if the patient has been seen within the past three years or had another care management service within the past year. (CMS)
24/7 access and continuity: APCM requires 24/7 access for urgent needs, real-time access to the patient’s medical information, and continuity workflows including routine appointment scheduling. (CMS)
Comprehensive care management and care plan: APCM includes systemic needs assessments, preventive services approaches, medication reconciliation and management, and an electronic patient-centered care plan that is accessible within and outside the billing practice as appropriate. CMS also requires providing a copy of the care plan to the patient or caregiver. (CMS)
Care transitions and follow-up: APCM includes transition coordination with timely exchange of electronic health information and timely follow-up communication within seven days of discharge from certain settings as clinically indicated. (CMS)
Population-level management and enhanced communication: APCM includes population-level analysis for gaps in care and risk stratification and requires offering asynchronous non-face-to-face consultation methods besides the phone. (CMS)

These elements are exactly where pharmacies can deliver disproportionate operational value.

IV. The operating model: pharmacy as the clinical extension team

The cleanest way to describe the model is not “leased employee.” It is “operational delegation under clinical direction.”

Core principle

The billing practitioner remains responsible for the patient’s overall care and the billed service. Pharmacy staff can execute defined operational tasks as auxiliary personnel under the billing practitioner’s direction, consistent with state law and supervision requirements. (Legal Information Institute)

A practical RACI split for APCM

This is an operating template, not a legal instruction.

Billing practitioner owns

Patient eligibility and assignment to APCM level
Initiating visit requirement and documentation
Oversight of the care plan and clinical direction
Clinical decisions that require practitioner judgment
Final responsibility for billed service documentation

Pharmacy team can execute

Consent capture workflow support and evidence packaging (the billing practice documents consent) (CMS)
Medication reconciliation workflow, adherence outreach, and self-management support (separated from dispensing tasks) (CMS)
Care plan data gathering, draft updates, and patient-facing distribution workflow support (CMS)
Transition follow-up tasking and coordination logistics, with escalation protocols (CMS)
Population-level gap lists and risk stratification inputs, depending on data access and agreement (CMS)
Documentation assistance and audit packet assembly for the billing practice

What makes the model fail

Pharmacy work that is primarily dispensing-associated being represented as Part B care management
No real 24/7 access workflow or no real-time access to medical information as required (CMS)
No care plan artifact that is routinely accessible and updatable by the care team (CMS)
No clear assignment of one provider per month or weak consent documentation (CMS)

V. Contracting and compliance: how funds should flow without creating obvious risk

If you want the model to survive scrutiny, treat the contract as part of the compliance design.

Baseline structure (high-level)

The billing practitioner bills Medicare for APCM when requirements are met
The pharmacy is paid under a services agreement for defined operational services

Key guardrails to include in the program design

Compensation should be consistent with fair market value and commercial reasonableness for the services actually performed
Avoid compensation that looks like payment for referrals or volume of federal program business
Define which activities are excluded because they are paid under Part D dispensing mechanics
Require documentation standards and audit cooperation obligations

CMS’s own language reinforces that incident to services must comply with applicable state law and supervision requirements and that payment cannot also be made under Part D for pharmacist-provided incident to services. (Legal Information Institute)

VI. Documentation: the minimum viable “audit packet”

APCM is not time-based, but it is not documentation-free. A defensible program produces the artifacts that map to the requirements.

A minimal audit packet should include:

Consent record or evidence of documented consent and start date (CMS)
Initiating visit evidence or exception basis for the patient (CMS)
Current care plan, with evidence it is electronic, routinely accessible, updatable by the care team, and provided to patient or caregiver (CMS)
Medication reconciliation and management artifacts with explicit clinical intent, not dispensing logistics (CMS)
Care transition follow-up logs and timely follow-up documentation when applicable (CMS)
24/7 access and continuity evidence: call routing rules, on-call coverage documentation, real-time access mechanism (CMS)
Population-level management outputs: gap lists, risk stratification logic, outreach lists (CMS)
Supervision and role documentation: how the billing practitioner directs and oversees auxiliary personnel, with escalation pathways (Legal Information Institute)

If you cannot produce these artifacts quickly, the program is not operationalized.

VII. Implementation roadmap: build the system before you sell the promise

Days 1 to 14: Compliance design and partner selection
- Choose the physician or NPP who will be responsible for primary care and meet APCM billing requirements (CMS)
- Map your state scope of practice constraints for pharmacists and technicians and define allowable tasks
- Define the pharmacy firewall boundary: what work is dispensing-associated and excluded from Part B
Days 15 to 30: Workflow build
- Build consent capture workflow and evidence retention (CMS)
- Build care plan workflow: data gathering, update cadence, patient distribution, team access model (CMS)
- Build 24/7 access model: escalation logic, urgent access routing, real-time medical info access (CMS)
- Build transition follow-up workflow with time targets and documentation templates (CMS)
Days 31 to 60: Pilot and harden
- Pilot with a small cohort of APCM patients
- Run internal audits on artifact completeness against CMS APCM requirements (CMS)
- Lock down division of responsibilities and escalation paths
Days 61 to 90: Scale
- Expand to additional clinicians and panels
- Standardize monthly audit packet generation
- Add population-level management outputs and gap closure workflows (CMS)

Technology note

This model fails without a real care management system that can separate dispensing from clinical documentation and can assemble audit artifacts without manual reconstruction. Any platform you use should be evaluated against APCM’s explicit operational requirements and the incident to supervision and role constraints. (CMS)

Conclusion

Waiting for provider status is a policy strategy. Implementing APCM through an incident to operating model is an operational strategy. The difference is that operations can be executed now, if you respect the actual regulatory mechanics:

APCM is billed by a physician or eligible NPP as a monthly bundle with explicit operational requirements (CMS)
Incident to allows auxiliary personnel, including leased and contracted staff, under supervision and state law constraints (Legal Information Institute)
Designated care management services can be furnished under general supervision when provided incident to, reducing the physical-location barrier (Legal Information Institute)
CMS explicitly clarified pharmacists are auxiliary personnel and may provide incident to services under appropriate supervision when not paid under Part D (CMS)

References

42 CFR 410.26, Services and supplies incident to a physician’s professional services (definitions, auxiliary personnel, and general supervision allowance for designated care management services). (Legal Information Institute)
CMS, Advanced Primary Care Management Services (APCM) overview and billing requirements, updated January 26, 2026. (CMS)
CMS MLN Matters, MM13887: Medicare Physician Fee Schedule Final Rule Summary, CY 2025 (APCM finalized as new coding and payment effective January 1, 2025). (CMS)
CMS Transmittal R10505CP (Dec 4, 2020): clarification that pharmacists fall within auxiliary personnel and may provide incident to services under appropriate supervision if payment is not made under Part D. (CMS)
CMS, Incident To Services and Supplies page (overview of incident to billing concepts and requirements). (CMS)

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This allows you to scale your own program without losing quality, breaking trust with physicians, or losing control of your revenue. We provide the precision of an automated medical director without the chaos.

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