As Medicare continues its push toward value-based care, APCM Medicare programs have emerged as a vital component in expanding access, improving outcomes, and rewarding proactive patient engagement.
What Is APCM?
Advanced Primary Care Management (APCM) refers to a suite of care management services recognized by the Centers for Medicare & Medicaid Services (CMS) that promote ongoing, coordinated patient care beyond traditional office visits. These services, billed under Medicare Part B, focus on improving outcomes through proactive, relationship-based care.
Eligibility and Coverage
For providers, understanding APCM Medicare eligibility ensures accurate billing and compliance with CMS guidelines:
- Patients with one or more chronic conditions that are expected to last at least 12 months or until the patient’s death
- Patients who have had a visit with the primary care provider in the past three (3) years
- Verbal or written consent from the patient to receive ongoing APCM services
APCM Medicare services are provided under the general supervision of a physician or other qualified health care professional who serves as the continuing focal point for all needed health care services, directing the clinical staff who deliver these services.
Eligibility by Tier
Tier 1 – G0556
Clinical staff provide APCM services under the direction of the physician or qualified health care professional responsible for all primary care needs. The services must include all required elements listed under CMS’ Advanced Primary Care Management Services guidelines.
Tier 2 – G0557
The patient meets all criteria for Tier 1 (G0556) and has two or more chronic conditions expected to last at least 12 months or until death. These conditions must place the patient at significant risk of death, acute exacerbation, or functional decline. The services must include all requirements for code G0556.
Tier 3 – G0558
The patient meets all criteria for Tier 1 (G0556) and is a Qualified Medicare Beneficiary (QMB) with two or more chronic conditions expected to last at least 12 months or until death. These conditions must place the patient at significant risk of death, acute exacerbation, or functional decline. The services must include all requirements for code G0556.
Coverage
Medicare reimburses APCM services monthly for time spent by qualified clinical staff under general supervision. Covered services include:
- Non-face-to-face care coordination
- Care plan management and updates
- Patient communication and education
- Follow-up between visits
These services are billed using G0556–G0558, depending on patient eligibility and complexity level.
Patient Cost-Sharing
While APCM services are covered under Medicare Part B, patients are responsible for standard 20% coinsurance, unless they have supplemental coverage or secondary insurance that offsets these costs. Educating patients about the value and frequency of these services helps reduce confusion and supports stronger participation.
Provider Requirements
To bill APCM codes accurately, providers must:
- Document all care coordination activities
- Maintain and update a comprehensive care plan.
- Ensure 24/7 access to care management services for patients.
- Use certified EHR technology to track and report data.
CMS allows billing for both physician and qualified health professional time, making APCM programs accessible to a wide range of clinical teams.
How APCM Fits Within the Medicare Framework
APCM services are an extension of Medicare’s care management initiatives aimed at improving outcomes through proactive engagement. They fit within Medicare Part B’s structure, reimbursing providers for non-face-to-face clinical time spent managing complex patients.
These services complement other value-based models by:
- Reducing hospitalizations and ED visits
- Improving medication adherence and preventive care
- Generating new, recurring revenue streams for practices
When integrated effectively, APCM Medicare services support a smoother transition to value-based care and lays the groundwork for participation in Accountable Care Organizations (ACOs) or Primary Care First programs.
Turning Data Into Actionable Insight
Beyond enabling day-to-day care coordination, TimeDoc Health empowers organizations to operationalize clinical and claims data to identify care gaps, predict risk, and measure impact. The platform synthesizes real-time patient data with quality, risk, and performance metrics, helping providers pinpoint which populations will benefit most from APCM Medicare services. By transforming raw data into actionable insights, care teams can make informed decisions, close gaps faster, and demonstrate measurable outcomes that align with Medicare’s quality and cost-containment goals.
The TimeDoc Health Advantage
At TimeDoc Health, we simplify APCM implementation by combining:
- Care management staffing
- EHR-integrated technology
- Compliance-driven workflows
- Data-driven insights that identify at-risk patients and track outcomes
Our solution helps practices seamlessly launch or expand care management programs, improve quality scores, and unlock sustainable Medicare reimbursement.
As Medicare continues to evolve, APCM represents a critical bridge between fee-for-service and value-based care. Understanding eligibility, billing, and operational requirements empowers providers to deliver more continuous, coordinated, and patient-centered care, while strengthening financial performance.
TimeDoc Health partners with organizations to make APCM Medicare programs simple, scalable, and impactful, transforming the way care is delivered across chronic and preventive populations.