CMS Proposes New Reimbursement for Advanced Primary Care Management Services
Last week, the Centers for Medicare & Medicaid Services (CMS) released the 2025 Medicare Physician Fee Schedule Proposed Rule (the Proposed Rule). In alignment with the U.S. Department of Health and Human Services (HHS) Initiative to Strengthen Primary Health Care, CMS introduced new reimbursement opportunities for primary care practices providing what they refer to as “enhanced care management” for their patients. As we discussed in our overview of the Proposed Rule, CMS drew from lessons learned through the CPC, CPC+, and Primary Care First demonstration models established by its Innovation Center in creating three new HCPCS codes for Advanced Primary Care Management (APCM) services, presumably in an effort to further prepare primary care physicians who are used to operating in a Fee For Service landscape for the shift to value-based care.
The new APCM codes are stratified into three levels based on patient risk. They integrate elements from the existing Chronic Care Management (CCM), Principal Care Management (PCM), and Communications Technology-Based Services (CTBS -- including virtual check-ins, remote evaluation of images, e-visits, and interprofessional consults) into a monthly services bundle that, unlike the existing care management codes, is not based on time spent by practitioners or clinical staff. This integration is intended to provide patients with a broader range of services options to meet their individualized needs while streamlining the billing process for practices into one code set.
The New Advanced Primary Care Management HCPCS Codes
HCPCS codes GPCM1 through GPCM3 describe APCM services furnished per calendar month by the practitioner assuming the care management role for a beneficiary.
GPCM1: Advanced primary care management services provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month. Proposed valuation: $10/month
GPCM2: Advanced primary care management services for a patient with multiple (two or more) 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, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the elements included in GPCM1, as appropriate. Proposed valuation: $50/month
GPCM3: Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple (two or more) 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, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the elements included in GPCM1, as appropriate. Proposed valuation: $110/month
Under the Proposed Rule, physicians and non-physician practitioners – for example, nurse practitioners (NPs) and physician assistants (PAs) – can order and bill for APCM services. Notably, CMS specifically states that the practitioner who bills for APCM services intends to be responsible for the patient’s primary care and is the continuing focal point for all needed health care services. CMS also indicates that the codes are intended primarily for primary care specialties such as general medicine, geriatric medicine, family medicine, internal medicine, and pediatrics. Finally, CMS anticipates that the APCM codes could potentially be billed for every patient of a primary care practice.
It is important to note that the proposed codes are not time-based. Instead, CMS focuses on getting the right care management services to a patient in the way that makes the most sense for that patient. Further, CMS explicitly states that the APCM codes are “designated care management services” that may be provided by auxiliary personnel under the “general supervision” of the billing practitioner – meaning, auxiliary staff need not be located in the same physical location as the practitioner.
See the chart below comparing reimbursement for PCM and CCM services provided by clinical staff to reimbursement for APCM services provided by clinical staff.
APCM Service Elements
The new APCM code set requires 13 service elements, many of which are already in place for practitioners currently providing CCM and PCM services. All service elements must be “available” to patients in a primary care practice, but the Proposed Rule specifically notes that not all service elements need to be provided each month. These service elements can be summarized as follows:
Patient Consent: Inform the patient about the service, obtain consent, and document it in the medical record.
Initiating Visit: for new patients or those not seen within three years.
24/7 Access: Provide patients with urgent care access to the care team/practitioner at all times.
Continuity of Care: Ensure continuity with a designated team member for successive routine appointments.
Alternative Care Delivery: Offer care through methods beyond traditional office visits, such as home visits and extended hours.
Comprehensive Care Management:
Conduct systematic needs assessments.
Ensure receipt of preventive services.
Manage medication reconciliation and oversight of self-management.
Electronic Care Plan: Develop and maintain a comprehensive care plan accessible to the care team and patient.
Care Transitions Coordination: Facilitate transitions between healthcare settings and providers, ensuring timely follow-up communication.
Ongoing Communication: Coordinate with various service providers and document communications about the patient’s needs and preferences.
Enhanced Communication Methods: Enable communication through secure messaging, email, patient portals, and other digital means.
Population Data Analysis: Identify care gaps and offer additional interventions.
Risk Stratification: Use data to identify and target services to high-risk patients.
Performance Measurement: Assess quality of care, total cost of care, and use of Certified EHR Technology.
Key Takeaways
The new APCM codes are intended to encourage primary care practices to adopt best practices from Advanced Primary Care delivery models and prepare physicians for the shift away from Fee For Service billing towards value-based care and payment mechanisms. However, adoption of the APCM codes is likely to hinge on reimbursement amounts and whether those amounts adequately cover the cost of implementing the required service elements.
The APCM codes provide reimbursement that would not otherwise be available for care management services provided to patients in instances where practitioners/clinical staff have not met the minutes requirements required for billing CCM or PCM services.
Because the APCM codes are not time-based, they open the door to use of AI technologies that can automate certain care management tasks, freeing up practitioners and clinical staff to use their clinical/medical judgment where it is most needed and practice at the top of their license.
How Nixon Gwilt Law Can Help
Your feedback to these proposals is important! We’ve seen stakeholder comments directly impact the substance of the final fee schedule on numerous occasions. We encourage you to submit comments to CMS by no later than September 9, 2024, and we’re here to help! Contact us today.
A special thanks to Morgan Menzies and Mallie Brocato, our summer law clerks, for their assistance with this article.