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 Final 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.
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.
The main differences between Chronic Care Management or Principal Care Management include:
The three new codes would include GPCM1, GPCM2, and GPCM3, which the practitioner of record can bill per patient per month.
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’ final 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.
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.
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.
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.
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:
ThoroughCare equips care managers to carry out all aspects of their duties through proven, reliable standards, systems, and workflow. Care managers can use ThoroughCare to make an impact with patients.
ThoroughCare helps providers, based on their specific needs, build new care programs or scale existing services. We support a comprehensive software platform, clinical advisory expertise, and reporting tools for quality improvement.
ThoroughCare offers:
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.
The proposed Advanced Primary Care Management program is different in four ways:
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.