Medicare payment for advanced primary care management coming 2025

On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Physician Fee Schedule (MPFS) 2025 final rule (the Final Rule), which establishes new advanced primary care management (APCM) billing codes that will expand opportunities for physician practices, federally qualified health centers (FQHCs), rural health clinics (RHCs) and other health care providers to get paid for services provided by clinical staff under the direction of a physician, nurse practitioner or physician assistant beginning January 1, 2025.

The new APCM billing codes incorporate elements based on current CPT codes for chronic care monitoring (CCM), transitional care management (TCM), and principal care management (PCM) and will be divided into three levels based on the number of chronic conditions and whether the beneficiary is enrolled as a Qualified Medicare Beneficiary.  All three of these HCPCS codes (G0556, G0557 and G0558) will apply to APCM services provided by clinical staff and directed by a physician or other qualified health care professional, such as a nurse practitioner or physician assistant, who is responsible for all primary care and serves as the continuing focal point for all needed health care services. Unlike CCM and PCM, the proposed APCM codes do not include a time threshold. The approximate monthly national payment amounts are projected to be:

• G0556 (Level 1): APCM services for a patient with no more than one chronic condition ($15)
• G0557 (Level 2): APCM services for a patient with multiple chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline ($50)
• G0558 (Level 3): APCM services for a patient who is a Qualified Medicare Beneficiary with multiple chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline ($110).

CMS requires the following APCM service elements and capabilities for all three APCM codes:

• Beneficiary consent must be obtained and documented in the medical record. The beneficiary must be informed that APCM services are available, that only one practitioner can furnish and be paid for these services during a calendar month, that the beneficiary has the right to stop services at any time (effective at the end of the calendar month), and that cost sharing may apply. CMS expects the practitioner to inform the beneficiary that the practitioner intends to assume responsibility for all of the patient’s primary care services and serve as the continuing focal point for all needed health care services, but that the consent does not limit the patient’s option to receive Medicare covered health care services from other practitioners
• An initiating visit will be required unless either the beneficiary has been seen by the practitioner or another practitioner in the same practice within the past three years, or the beneficiary received another care management service (such as APCM, CCM, or PCM) within the previous year from the practitioner or another practitioner in the same practice.
• The practice must provide 24/7 access to the care team or practitioner to discuss urgent care needs, must have the capability to deliver care outside normal office visits to meet the patient’s needs (such as home visits or expanded hours), and must offer continuity of care with a designated member of the care team with whom the patient can schedule successive routine appointments. The person responding to a patient after-hours is expected to communicate the interaction to the primary care team or practitioner.
• The practice must provide overall comprehensive care management, such as systematic medical and psychosocial needs assessment, system-based approaches to ensure timely receipt of preventive care services, medication reconciliation and management, and oversight of patient medication self-management.
• An electronic patient-centered comprehensive care plan needs to be maintained and updated, must be timely available within and outside the practice to individuals involved in the beneficiary’s care, and a copy must be provided to the patient or caregiver. CMS expects a care plan to outline the patient’s health goals, needs, and self- management activities and to be patient-friendly and accessible to the patient.
• The practice needs to manage care transitions. This element includes coordination of care transitions between and among health care providers and settings, follow-up after an emergency department visit or discharge from a health care facility, timely exchange of electronic health information to support continuity of care, and follow-up communication with the patient or caregiver within 7 days of discharge, as clinically indicated.
• The practice needs to provide ongoing communication and coordination of services of practitioners, home-based and community based service providers, community-based social service providers, hospitals, skilled nursing facilities and other facilities, as well as medical record documentation of communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors.
• The beneficiary and any caregiver must have enhanced opportunities for ongoing communication with the care team or practitioner through asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, as well as other communication technology-based services. The practice needs to ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins, digital online assessment and management, and E/M visits (or e-visits).
• The patient population-level management element involves population-based, data-driven approaches to manage preventive and chronic care and implement strategies to improve care and outcomes. The practice is required to analyze patient population data to identify gaps in care and offer additional interventions as appropriate, and to stratify risk of the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients. Participation in a Shared Savings Program ACO, REACH ACO, Making Care Primary, or Primary Care First would satisfy this element.
• Performance needs to be assessed for primary care quality, total cost of care, and meaningful use of certified electronic health record technology (CEHRT). A MIPS-eligible clinician can register for and report the Value in Primary Care MVP. A practitioner who is part of a Tax Identification Number (TIN) participating in a Shared Savings Program ACO would satisfy this requirement through the ACO’s reporting of the APM Performance Pathway. A practitioner who is participating in a Shared Savings Program ACO, REACH ACO, Making Care Primary, or Primary Care First would satisfy this requirement through the quality reporting, assessment and performance requirement and other program and model requirements.

CMS acknowledged that not all APCM elements are required to be provided each month to a given patient, but that the billing practitioner and auxiliary personnel must have the ability to provide all APCM elements as appropriate for the patient.

CMS has identified services and related billing codes that overlap substantially with APCM services and therefore are not allowed to be billed in the same period as APCM by the same practitioner or another practitioner within the same practice for the same patient. These “duplicative” services include CCM, PCM and TCM, as well as specified communication-based technology CPT codes for inter-professional consultation, remote evaluation of patient videos/images, virtual check-in, and e-visits.

In contrast, CMS identified other care management services as potentially complementing, rather than overlapping or duplicating, APCM, including behavioral health integration (BHI), services addressing health-related social needs (HRSNs), remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM), so CMS will allow concurrent billing of those services and APCM when appropriate.

While CMS is not limiting APCM to particular physician specialties, the APCM codes may be particularly attractive for physicians who participate in a Shared Savings Program ACO or REACH ACO, or in a Making Care Primary or Primary Care First model. CMS stated in the Final Rule: “We anticipate that a practitioner using the advanced primary care model will bill for APCM services for all or nearly all the patients for whom they intend to assume responsibility for primary care.”

The Final Rule is scheduled to be published in the Federal Register on December 9, 2024.

For more information on the MPFS 2025 Final rule or care management services, please contact attorney Rick Hindmand.