The Only Guide You Need for Advanced Primary Care Management (APCM)

This guide explores APCM in detail, including its structure, eligibility criteria, implementation requirements, and how it compares to other care management models. 

What is Advanced Primary Care Management? 

APCM is a Medicare program that rewards primary care providers for delivering proactive, patient-centered care. Instead of billing for individual services, providers receive monthly payments based on their ability to offer comprehensive care management. The goal is to reduce hospitalizations and emergency room visits, improve chronic disease management, and ensure patients receive timely support.  
 
Unlike reactive care models, APCM focuses on early interventions, continuous monitoring, and personalized care plans. 

Key Features of APCM 

1. Preventative Focus: APCM emphasizes early interventions, such as regular health screenings and medication reviews, to address issues before they escalate. 

2. 24/7 Access: Patients can contact their care team at any time via phone or text for urgent concerns, reducing reliance on emergency rooms. Outsourcing care can be provided with vendors that comply with CMS guidelines and work under the supervision of qualified providers. 

3. Team-Based Care: Nurses, care managers, and physicians collaborate to create personalized care plans that address medical, social, and behavioral needs. 

4. Patient Stratification: Medicare beneficiaries are grouped into three levels based on health complexity, ensuring resources match patient needs. 

APCM shares similarities with Chronic Care Management (CCM) but differs in its reimbursement structure and broader scope. For example, while CCM focuses on monthly time-based services, APCM reimburses providers for maintaining care availability—even if patients don’t use all services monthly. 

Patients enrolled in APCM cannot simultaneously participate in CCM or other overlapping programs. 

Eligibility and Patient Stratification 

APCM requires providers to categorize Medicare patients into three tiers: 

Level 1: Low Complexity 

• Patients: Those with one or fewer chronic conditions (e.g., mild hypertension). 

• Care Needs: Basic preventative services, annual wellness visits, and medication reviews. 

• Reimbursement: $15 per patient/month. 

Level 2: Moderate Complexity 

• Patients: Those with two or more chronic conditions (e.g., diabetes and heart disease). 

• Care Needs: Regular monitoring, care plan updates, and specialist coordination. 

• Reimbursement: $50 per patient/month. 

Level 3: High Complexity 

• Patients: Those with multiple chronic conditions who are also Qualified Medicare Beneficiaries (QMB)—a status indicating financial hardship. 

• Care Needs: Intensive care coordination, social support referrals, and frequent follow-ups. 

• Reimbursement: $110 per patient/month. 

To verify QMB status, providers use the HIPAA Eligibility Transaction System (HETS). Level 3 patients are exempt from coinsurance, reducing financial barriers to care. 

Core Services Included in APCM 

APCM integrates several existing care management programs into a single framework: 

Chronic Care Management (CCM) 

• Ongoing support for conditions like diabetes or COPD. 

• Care managers monitor symptoms, coordinate with specialists, and update treatment plans. 

Transitional Care Management (TCM) 

• Ensures safe transitions after hospital discharges. 

• Providers contact patients within two days of discharge and schedule follow-ups within seven days. 

Principal Care Management (PCM) 

• Focused on managing single high-risk conditions (e.g., advanced kidney disease). 

• Involves weekly check-ins and tailored care plans. 

Digital Health Tools 

• Virtual Check-Ins: Brief consultations via phone or video to address minor concerns. 

• Remote Monitoring: Tracking vital signs (e.g., blood pressure) using wearable devices. 

• Electronic Visits (e-Visits): Secure messaging for non-urgent issues like prescription refills. 

For example, a patient with diabetes might receive monthly CCM check-ins, remote glucose monitoring, and same-day responses to medication questions—all under APCM. 

Actuvi streamline care coordination by offering real-time health data tracking, automated patient reminders and digital health tools. Actuvi’s dashboard enables providers to monitor patient compliance, review abnormal readings, and allocate billing codes automatically. 

Program Requirements for Providers 

To qualify for APCM reimbursements, practices must meet CMS guidelines: 

1. Patient Consent 

• Obtain written consent explaining program benefits and potential costs. 

• Document consent in the patient’s electronic health record (EHR). 

Actuvi will automate this with the patient signing a consent form electronically the first time they sign into the app 
 

2. Initial Visit 

• Conduct an in-person visit if the patient hasn’t been seen in three years. 

• Use this visit to assess health status and create a baseline care plan. 
   

3. 24/7 Availability 

• Maintain a dedicated phone line staffed by care teams. 

• Train staff to handle after-hours calls and escalate urgent issues. 

This can be performed by outsourced teams for the afterhours or all the time. Actuvi allows you to integrate outsourced teams easily into your program. 
 

4. Care Continuity 

• Assign patients to a consistent care team to build trust. 

• Avoid frequent changes in care managers or providers. 

Actuvi makes this simple with teams features that ensure that the care is shared with a team that can make it easy on your staff. 
 

5. Comprehensive Care Plans 

• Develop plans collaboratively with patients, including goals like “reduce blood sugar levels” or “attend physical therapy sessions.” 

• Update plans quarterly or after significant health changes. 

Actuvi will help you build your plans during implementation and allow you to track and monitor easily. 
 

6. Quality Reporting 

• Track metrics like vaccination rates, emergency room visits, and patient satisfaction. 

• Report data to CMS through the Merit-Based Incentive Payment System (MIPS). 

Actuvi’s platform allows you to track any data set or indicator – put it into a chart to easily evaluate. 

Actuvi’s platform supports these requirements by enabling patient stratification, care plan updates, and performance tracking. Its analytics tools identify high-risk patients, enabling timely interventions. 

How APCM Compares to Other Programs 

APCM complements but differs from other Medicare programs: 

Aspect	APCM	CCM	TCM
Billing	Monthly payment for service availability	Payment based on time spent (20+ minutes)	Single payment per care transition
Focus	Preventative care and chronic management	Chronic condition management	Post-hospitalization transitions
Patient Complexity	Stratified into three levels	No stratification	Focused on high-risk transitions
Quality Reporting	Mandatory	Optional	Optional

Key Differences 

• APCM vs. CCM: APCM doesn’t require monthly calls but mandates 24/7 access. 

• APCM vs. TCM: TCM addresses single transitions (e.g., hospital to home), while APCM offers ongoing support. 

APCM’s bundled payment structure rewards practices for maintaining service capabilities rather than tracking time. This reduces administrative burdens and encourages proactive care. 

Billing and Reimbursement 

APCM uses three billing codes: 

• G0556 (Level 1): $15/month for low-complexity patients. 

• G0557 (Level 2): $50/month for moderate-complexity patients. 

• G0558 (Level 3): $110/month for high-complexity QMB patients. 

Billing Best Practices 

• Bill once monthly per patient, regardless of service usage. 

• Use EHR systems to track patient levels and automate code assignment. 

• For QMB patients, waive coinsurance to comply with Medicare rules. 

Actuvi automates billing code assignment, tracks monitoring, and generates billing reports, minimizing revenue cycle delays.  

For Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), APCM offers an alternative to expiring G0511 codes. Starting July 2025, these clinics must adopt standard CPT codes (e.g., 99490) for care management. APCM’s higher reimbursements for Level 3 patients may offset financial challenges for clinics serving low-income populations. 

Implementing APCM in Your Practice 

Step 1: Assess Readiness 

• Evaluate existing workflows: Do staff have capacity for care coordination? 

• Audit technology: Can your EHR handle patient stratification and reporting?  
   
  Actuvi can make it simple and easy to add without requiring you to change EHRs. 

Step 2: Train Staff 

• Educate care teams on APCM requirements, including consent protocols and emergency response procedures. Actuvi will work with you to ensure your team is prepared and compliant. 

• Role-play common scenarios, like handling after-hours patient calls. 

Step 3: Partner with Technology Vendors 

• Platforms like Actuvi offer a platform to run your program with all the essential components for reimbursement. The only thing you need is to provide care. 

• Integrate wearable devices (e.g., glucose monitors) to streamline data collection. 

Step 4: Educate Patients 

• Use brochures or videos to explain APCM benefits. 

• Address concerns like, “Will this cost me more?” or “How do I reach my care team at night?” 

Actuvi simplifies implementation by offering pre-built care tracks (e.g., post-operative or diabetes management), customizable assessments, and population-level notifications. Its analytics dashboard tracks KPIs like patient compliance and response rates, enabling continuous program optimization. 
 

Common Challenges and Solutions 

Challenge 1: Staff Shortages 

• Solution: Partner with third-party care management companies to handle after-hours calls and data entry. 

Challenge 2: Patient Engagement 

• Solution: Use automated reminders for appointments and medication refills. 

Challenge 3: Compliance Risks 

• Solution: Conduct monthly audits to ensure care plans are updated and consents are documented. 
   

The Future of Value-Based Care 

APCM represents a significant step toward sustainable healthcare. By aligning payments with outcomes, it incentivizes preventive care, reduces hospitalizations, and fosters patient engagement. For practices, success hinges on leveraging technology to meet CMS requirements while maintaining care quality. 

Platforms like Actuvi are critical to this transition, providing all the tools that ensure compliance, automate workflows, and provide actionable insights. As healthcare continues evolving, APCM will likely serve as a blueprint for future value-based initiatives. 

Conclusion 

Advanced Primary Care Management offers a practical path for Medicare providers to improve patient health while ensuring financial stability. By focusing on prevention, care coordination, and patient stratification, practices can enhance quality of life for vulnerable populations. While implementation requires upfront effort—staff training, technology upgrades, and patient education—the long-term benefits make APCM a worthwhile investment for clinics committed to value-based care. 

Partnering with Actuvi and leveraging automation tools will further simplify the transition, allowing providers to focus on what matters most: patient care. 

Partner with Actuvi navigate APCM’s complexities efficiently, ensuring compliance and maximizing the program’s potential – https://dub.sh/digitalclinic.