By HealthArc | October 11, 2024

Proposed Advanced Primary Care Management

The Proposed Rule for the 2025 Medicare Physician Fee Schedule plans to introduce a new preventative care program, called Advanced Primary Care Management (APCM) with new billing codes. This program will be available for primary care practices, including general practice, geriatric care, family practice, and internal medicine. With the aim to transform preventative care by combining multiple care management and telehealth programs into a single program, an APCM program will incorporate the functionalities of:

Only a handful of specialists who serve as a primary source of care, like cardiologists and OB-GYNs can offer this program.

Unlike other care management programs, APCM expands eligibility and introduces new billing codes that are not time-based. One of the key differences in Advanced Primary Care Management compared to existing care management programs is that it expands eligibility to all Medicare patients.

Table of Contents

Advanced Primary Care Management Codes & Risk Stratification Levels 2025

The three new proposed APCM codes are GPCM1, GPCM2, and GPCM3 and will represent different payment levels for primary care services provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for providing the necessary primary care and serves as the ongoing focal point for health care services required by a patient in a calendar month.

GPCM1 (Level 1): Advanced primary care management services for Medicare patients with no more than one chronic condition and seen by the billing provider in the last 36 months.

Proposed Valuation: $10 per patient, per month reimbursement

GPCM2 (Level 2): Advanced primary care management services for Medicare patients with two or more chronic conditions that are expected to last at least 12 months or until the death of the patient. These conditions place the patient at significant risk of death, acute exacerbation, or functional decline. The patient must have been seen by the billing provider in the last 12 months.

Proposed Valuation: $50 per patient, per month reimbursement

GPCM3 (Level 3): GPCM3 covers advanced primary care management services for a Qualified Medicare Beneficiary (QMB). These patients have two or more chronic conditions expected to last at least 12 months or until death. These conditions place the patient at significant risk of death, acute exacerbation, or functional decline and the patient must have been seen by the billing provider within the last 12 months.

Proposed Valuation: $110 per patient, per month reimbursement

Advanced Primary Care Management Program Is Not Time Based

The removal of time thresholds makes Advanced Primary Care Management program different from other care management programs, enabling the providers to focus on care rather than honoring the time requirements.

Clinical staff can also adjust care delivery based on characteristics such as whether the patient has recently been admitted to the hospital, whether they are ill or dealing with complications from a chronic condition, and whether they have been taking their meds on time.

Depending on the patient’s needs, the clinical staff can assist with treatment plans and goals, guide them to local community resources, or make appointments and schedule medication refills.

Advanced Primary Care Management is provided under general supervision. This means that clinical staff can deliver the care services, while the patient’s provider oversees the entire process. Practices can collaborate with care management organizations to provide advanced care.

Service Elements For Advanced Primary Care Management

Patient Consent: Though all Medicare patients are eligible for receiving Advanced Primary Care Management services, they must give their consent or sign an agreement before starting to receive the required care. Patients must give documented consent to enroll in APCM. They cannot enroll in APCM while participating in other care management programs like CCM or PCM. Moreover, patients must also consent to cost-sharing, unless they are a Qualified Medicare Beneficiary. QMBs are exempt from copays and deductibles.
Initiating Visit for New Patients: New patients must undergo an initial visit, but it is not required if the patient has already seen the provider or another provider at the same practice in the previous three years. Initiating visit is also not necessary if the beneficiary has received CCM or PCM services from their provider or another provider at the same practice within the last year.
24/7 Access to Care: APCM services are available round the clock and a member of the care team who has access to the patients’ health records must be available to them at all times. The patient should be able to see the same member of the care team for subsequent routine sessions, and the practice should supplement typical office visits with convenient options such as extended clinical practice hours or home visits. Some remote care programs covered include:

- Inter-professional Internet Consultation
- Remote Evaluation of Patient Videos/Images
- Virtual Check-Ins
- Online Digital E/M (e-Visit)

Comprehensive Care Management: Comprehensive care management involves assessing both the physical and psychosocial needs of patients. This ensures that patients receive preventative care, help with managing their medications, and support for self-care.
Comprehensive Care Plan: Advanced Primary Care Management is a patient-centered care delivery model, where the care coordinators must work with patients to create, implement, revise and maintain an effective care plan documented in an electronic format. This document must be accessible to everyone involved in a patient’s care, right from the provider to the care team, and the patient’s family or caregiver(s).
Management of Care Transitions: Care providers must oversee the patient’s transition from one healthcare setting to another. Whether the patient has been referred to a specialist, discharged from the hospital, or returned home after an emergency visit, the care provider is responsible for ensuring continuity of care. The care provider/ manager must share electronic information regarding the care plan and transition with other providers involved in the patient’s care and must communicate with the patient within seven days of discharge from the practice or healthcare facility.
Care Coordination: Care providers must support patients in finding and receiving assistance from practitioners, home-based care providers, community-based services, social service organizations, hospitals, and skilled nursing institutions as required. They must also capture the patients’ psychosocial strengths, needs, and outcomes, keeping in regard their cultural and linguistic preferences.
Enhanced Communication: Advanced Primary Care Management is focused on streamlining the patient-provider communication via secure messaging, email, Internet, patient portal, or phone. Providers should also be able to communicate, review and evaluate pre-recorded media from patients, whether it’s images or videos. Healthcare practices must be able to provide digital communication options to patients, like virtual check-ins or e-visits.
Patient Population-Level Management: Practices must examine patient population data to detect care gaps and make timely interventions. They must also be able to risk-stratify their patients using the three levels of APCM, namely GPCM1 (Level 1), GPCM2 (Level 2), and GPCM3 (Level 3).
Performance Measurement: Unlike the existing care programs, APCM is focused on outcome-based care. Practitioners who are eligible for the MIPS program must register for the Value in Primary Care MIPS Value Pathway.. APCM is also available to providers who participate in other Medicare programs such as ACO Reach and Primary Care First.

APCM Can’t Be Billed With Other Care Management CPT Codes

CMS has identified services and related billing codes that significantly overlap with APCM services and hence cannot be invoiced at the same time as APCM by the same practitioner or another practitioner within the same practice for the same patient. These “duplicative” services include CCM, PCM, TCM, and 15 communication-based technology CPT codes for inter professional consultation, remote evaluation of patient videos/images, virtual check-in, and e-visits.

Also, CMS identified other care management services, such as behavioral health integration (BHI), health-related social needs (HRSNs), remote patient monitoring (RPM), and remote therapeutic monitoring (RTM) as potentially complementing, rather than overlapping or duplicating, and will allow concurrent billing of those services and APCM whenever and wherever appropriate.

For more detailed information on Advanced Primary Care Management program and how it could help your healthcare practice meets its patient outcome and engagement goals, feel free to contact HealthArc’s team at (201) 885 5571.