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Medicare | Care Management

What is Advanced Primary Care Management?

October 14th, 2024 | 9 min. read

Daniel Godla

Daniel Godla

Founder and CEO of ThoroughCare

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Over a decade, the Centers for Medicare & Medicaid Services (CMS) tested various value-based innovation models focused on improving primary care. Models like CPC, CPC+, and Primary Care First demonstrated that “comprehensive primary care can lead to reductions in emergency department and hospital visits while better meeting patient needs.”

In 2024, CMS introduced new reimbursement opportunities for primary care practices through the 2025 Medicare Physician Fee Schedule Proposed Rule. Referred to as enhanced care management, Advanced Primary Care Management (APCM) is meant to support primary care physicians in their transition to value-based care. Ultimately, their goal is to promote longitudinal relationships between clinicians and patients while reimbursing for risk-stratified care management services.

If approved, the APCM program would go into effect January 1, 2025.

What is Advanced Primary Care Management?

APCM proposes three new reimbursement codes based on three levels of patient risk. 

These services would consist of integrated elements from existing Medicare care management programs, such as Chronic Care Management and Principal Care Management, as well as Communications Technology-based Services, but with distinct changes outlined here.

How is APCM different from CCM and PCM?

The main differences between Chronic Care Management or Principal Care Management include:

  • Coding is based on patient risk stratification and not time
  • There is no minimum time requirement but a focus on activities and outcomes
  • Care management is meant for all Medicare beneficiaries and not just those with one or more chronic conditions
  • Participation in quality measurement would be required   

Difference #1: APCM offers three risk-stratified HCPCS codes

The three new codes would include GPCM1, GPCM2, and GPCM3, which the practitioner of record can bill per patient per month. 

  • GPCM1 is geared toward patients with one or no chronic illness. It covers advanced primary care management services provided by clinical staff directed by a physician or other qualified healthcare professional. This clinician is responsible for delivering ongoing contact for all needed healthcare services. The proposed value for GPCM1 is $10 per patient per month with an RVU value of 0.17.
  • GPCM2 includes the basic elements of GPCM1 and is geared toward patients with two or more chronic conditions, which are expected to continue for at least 12 months and place the patient at significant risk of death, acute exacerbation, or functional decline. GPCM2 is $50 per patient per month with an RVU value of 0.77.
  • GPCM3 is appropriate for any patient who is a Qualified Medicare Beneficiary (QMB) and meets the criteria for GPCM2. GPCM3 is $110 per patient per month with an RVU value of 1.67.

A QMB is a Medicare beneficiary who receives assistance from their state to pay for Medicare costs. They are not legally required to pay for Medicare cost-sharing, including deductibles, co-insurance, and copays.

The core aspect of all three codes, as described in CMS’ proposed rule, is that the billing healthcare professional of record must be responsible “for all primary care and serves as the continuing focal point for all needed health care services.” 

While primarily intended for primary care specialties—family medicine, internal medicine, or geriatric medicine—specialists overseeing primary care for more complex patients could also participate.  They would have to act as the main point of coordination for all needed care.

In a team-based model where one care manager oversees numerous patients, the billing clinician of record would provide general supervision similar to existing care management programs. 

Difference #2: APCM focuses on activities and outcomes, not time

APCM codes are not time-based. They do not require meeting a minimum time requirement like CCM or PCM. Because the HCPCS codes for APCM bundle elements of CCM, PCM, Transitional Care Management, and Communications Technology-based Services, the focus is on activities that meet the patient’s needs at their risk level rather than the amount of time spent.

CMS intends to focus less on minutes spent on specific activities and more on providing comprehensive and accessible care management services in a delivery form that they prefer.  

Difference #3: APCM could be billed for every Medicare patient receiving primary care

CMS anticipates that the APCM program could be appropriate for every Medicare patient seen in a primary care practice. The three risk levels cover patients with one or fewer chronic conditions who may need a focus on preventative care, a new addition to the care management schema. 

Level two aligns with the typical CCM participant, and level three focuses on high-risk dual-eligible beneficiaries.

Difference #4: APCM requires quality measurement and reporting

Unlike traditional Medicare care management programs like CCM and PCM, APCM requires participation in quality measurement and reporting. Payments would be linked to the Value in Primary Care value pathway of the Merit-based Incentive Payment System. 

Providers already participating in the Medicare Shared Savings Program or advanced primary care models like ACO REACH and Making Care Primary have all the data available to meet this new requirement. 

Reporting would begin in 2026 based on the 2025 performance year.

What are the proposed requirements for APCM?

In addition to the differences mentioned above, APCM has requirements that overlap with programs like CCM, PCM, and TCM. However, some specifics stand out.

The new APCM program requires 13 service elements, which must be accessible to patients. However, not all service elements must be provided each month. It is up to the provider’s discretion which features are needed for which level of patient and when they should be implemented. 

The 13 elements include:

  • Patient consent: Similar to other care management programs—inform the patient about their program eligibility, cost-sharing, right to stop services, one practitioner can furnish/be paid, obtain consent, and document that consent in their medical record. If a practice already offers PCM or CCM, APCM requires re-enrolling and securing new consent.
  • Initiating visit: Provide an initiating visit unless the patient has been seen within three years or received other care management services (CCM, PCM, APCM) from another practitioner in the same practice in the previous year.
  • 24/7 access and care continuity: Patients must always have access to the care team or their practitioner for urgent needs. Additionally, one designated care team member must provide ongoing contact across appointments.
  • Patient-centered care delivery: Patients must have access to alternative care methods beyond traditional office visits, which may include home visits, expanded hours, etc.
  • Comprehensive care management: Similar to CCM and PCM, however, the focus is on a systematic and proactive approach to needs assessments, preventative services, medication reconciliation, and self-management.
  • Comprehensive and electronic care plan: Develop and maintain a comprehensive care plan accessible to the care team and patient. The plan should be patient-centered and available electronically inside and outside the billing practice.
  • Care transitions coordination: Timely communication, data exchange, and care coordination between healthcare settings and providers within seven days of discharge.
  • Practitioner, home, and community coordination: Continuous communication and coordination among different types of service providers, including social service providers and home- or facility-based services. Additional focus on documenting the patient’s psychosocial and functional needs, goals, and preferences.
  • Enhanced communication methods: Ensuring communication between the patient or family caregiver and the care team through asynchronous non-face-to-face methods beyond the telephone, including secure messaging, email, patient portals, and other digital means.
  • Patient population data management: Analyze patient population data to identify care gaps and offer interventions. Risk stratify patient populations on variables relating to the three levels.
  • Performance measurement: Document and report on quality of care performance, including total cost of care and use of Certified EHR Technology. Participation in MIPS, REACH ACO, and other primary care or shared savings programs meet quality requirements.

How ThoroughCare supports care management 

ThoroughCare is an end-to-end care management platform supporting elements of the proposed APCM program, including 

  • Full workflow for enrollment, care planning, screenings, and assessments
  • Educational resources to help patients understand their conditions 
  • Enhanced communication, including two-way secure text messaging and communication via portal and app 
  • Care coordination between primary care physicians, clinicians, and specialists
  • Automated documentation and claim preparation
  • Data analytics and population data management 
  • Data visualizations and dashboards to support quality measurement and patient engagement

We've built the most comprehensive tool for providers to implement enhanced care management. 

Care teams can control their own programs, support a deeper and more effective relationship with all their Medicare patients, and secure additional revenue for excellent care.

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Key questions answered

What is Advanced Primary Care Management (APCM)?

In 2024, CMS introduced new reimbursement opportunities for primary care practices through the 2025 Medicare Physician Fee Schedule Proposed Rule. Advanced Primary Care Management (APCM) is meant to support primary care physicians in their evolution toward value-based care. Its main aim is to improve provider/patient relationships while supporting reimbursement for risk-stratified care management services.

How is APCM different from existing Medicare care management programs?

The proposed Advanced Primary Care Management program is different in four ways:

  • APCM offers three new billing codes corresponding to three risk levels. Patients are to be stratified and invited to enroll in the most appropriate level for their needs.
  • APCM focuses on activities and not time. The monthly per patient per month rates cover all care management activities and do not have a required minimum to be billed.
  • APCM is available to all Medicare beneficiaries who may benefit because the first risk level includes patients with one or no chronic conditions.
  • APCM requires quality measurement and reporting, focusing further on value-based care.  

When will APCM go into effect and how would it affect CCM and PCM participants?

If CMS accepts the 2025 Medicare Physician Fee Schedule Proposed Rule, the new APCM program would be available January 1, 2025. Practices that already participate in CCM and PCM can also participate in APCM. However, a patient can only be enrolled in and billed under one monthly program. Patients enrolled in CCM or PCM would need to be re-enrolled in APCM.