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CMS has made some very exciting updates to Advanced Primary Care Management, or APCM, for 2026! With an expanded code set and increased reimbursement rates, this is the year to grow and expand this valuable service for your patients. In this video, we’ll discuss all the important updates one should know in order to properly code and bill for this program.
Advanced Primary Care Management is a newer Medicare program with a focus on patient outcomes. With no monthly time requirements, APCM focuses on ten service elements provided to patients monthly.
For 2026, CMS has added Behavioral Health components to the APCM program. Behavioral health is a big part of chronic disease management, so adding this to the APCM program is a great addition. Many patients need ongoing behavioral health support, so this will enable care teams to have more holistic care plans, better documentation support, and stronger continuity of care. It allows for easier billing of psychiatric care coordination and general BHI services alongside primary care management.
Be sure to download a reference guide for the 2026 APCM codes.
Keep in mind that the codes are based on national averages, which may vary in your area. For the exact current rate based on your location, visit the Physician Fee Schedule website.
First, let’s discuss the three risk stratification APCM HCPCS codes.
Risk Stratification APCM HCPCS Codes
First is code G0556. It is for patients with one or no chronic illnesses and covers services provided by clinical staff under the guidance of a physician or qualified healthcare professional. The current national average reimbursement rate for G0556 is about $16 per patient per month, which is up over a dollar from last year.
The next code is G0557. This code covers the key elements of G0556 and is intended for patients with two or more chronic conditions. These conditions are expected to last for at least 12 months and may put the patient at a high risk of death, sudden health decline, or loss of function. The national average payment rate for G0557 is $54 per patient per month, which is a nearly 4 dollar increase over last year.
The final code is G0558 and applies to any patient who is a Qualified Medicare Beneficiary and meets the criteria for G0557 with two or more chronic conditions. A Qualified Medicare Beneficiary, or QMB, is an individual who receives assistance from their state to help cover Medicare costs. Due to this support, they are not required to pay for Medicare cost-sharing, which includes deductibles, co-insurance, and copayments. The current national average reimbursement rate for G0558 is $117 per patient per month, which is up over 7 dollars from last year!
Behavioral Health Add-On Codes
And now, let’s look at the new Behavioral Health add-on codes for APCM. These codes are billed in addition to the previously mentioned APCM codes for the same patient in the same month. These services are meant to be directly comparable to existing Behavioral Health Integration (BHI) and Collaborative Care Model (CoCM) codes, but do not have the time-based rules associated with those programs.
First is G0568 for the Initial Collaborative Care Model (CoCM) month for APCM patients. The current national average reimbursement rate is about $162.
Next is G0569 for the Subsequent CoCM months for APCM patients. The current national average reimbursement rate is about $146.
And finally, G0570 for General BHI services for APCM patients. The current national average reimbursement rate is about $58.
With the reimbursement increases this year and new behavioral health opportunities, there’s a great opportunity to grow your program and offer this valuable service to more patients. If you need help in starting or growing your APCM program, reach out to us at ThoroughCare and we’d be happy to help.
