Instructions

Purpose

This tool helps your organization estimate the monthly margin improvement from using HCUnity across your care management programs.
It calculates both financial impact and operational savings based on your current patient volumes and program participation.

How It Works

The calculator adds up five areas of improvement:

• Recovered Revenue – Revenue gained from properly billing missed RPM, CCM, or TCM services.
• Labor Efficiency – Time saved through automated reporting and documentation.
• Denial Reduction – Fewer claim rejections or rework due to real-time compliance checks.
• Device Reuse/Deprecation Avoidance – Savings from reusing returned RPM devices.
• Quality Bonus Uplift – Additional value earned from improved outcomes and service-element tracking.

APCMFrom Centers for Medicare & Medicaid Services            Effective CY 2025

What Are Advanced Primary Care Management Services?

APCM services combine elements of several existing care management and communication technology-based services you may have already been billing for your patients.  This payment bundle reflects the essential elements of advanced primary care, including:

• Transitional care management (TCM)
• Advance Primary Care Management (APCM)

Communication technology-based services include:

• Virtual check-ins
• Remote evaluations of pre-recorded patient information
• Interprofessional consultations

APCM services allow you to:

• Provide patients with a wide range of services to meet their individual needs based on complexity
• Bill for these services using a monthly bundle (instead of billing for each service or recording minute by minute)

These services help simplify your billing and documentation requirements while ensuring that your patients have access to high-quality primary care services.

 Who Can Bill for APCM Services?

 Starting January 1, 2025, you can bill for APCM services if:

• You’re a physician or non-physician practitioner (NPP), including a nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS)
• You’re responsible for all of your patients’ primary care services
• You’re the focal point for all of your patients’ needed health care services
• You’ve gotten either written or verbal consent from your patient

APCM service codes are primarily used for primary care specialties, including general internal medicine, family medicine, geriatric medicine, and pediatrics.

How Often Can APCM Be Billed?

You can bill for APCM services once per patient per calendar month.  This helps remove some of the burden of billing with individual, time-based care management codes.

Individual care management codes have time-based billing requirements, where you need to document every minute you spend on care management, and you must meet certain thresholds each month to bill those services.  APCM services aren’t time-based, and you can bill using an APCM HCPCS code once per month when you meet the billing requirements.

What Are the APCM HCPCS Codes?

HCPCS Codes — Advanced Primary Care Management (APCM)

Centers for Medicare & Medicaid Services, Effective CY 2025

G0556      $15.20
Advanced primary care management services for a patient with one chronic condition [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], or fewer, 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.

Level 1 – Eligibility: For patients with one or fewer qualifying chronic conditions.

G0557      $48.84  
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.

Level 2 – Eligibility: For patients with two or more chronic conditions.

G0558      $107.07
Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary (QMB) 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.

Level 3 – Eligibility: For Qualified Medicare Beneficiary (QMB) patients with two or more chronic conditions.

 Notes / key points:

• “Chronic conditions” are defined as conditions expected to last at least 12 months (or until death) and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
• These codes are billed per calendar month.
• Only one of these codes may be billed per patient per month (you can’t bill G0556 and G0557 for the same patient in the same month).

What Are the APCM Billing Requirements?

To bill for APCM services, you must complete these elements when they’re clinically appropriate for the individual patient (you don’t have to provide all of these services every month):

• Get patient consent. Get written or verbal consent from the patient to participate in APCM services, and document it in the patient’s medical record. The consent must inform your patient that:
• Only 1 provider can furnish and be paid for APCM services during a calendar month
• They have the right to stop services at any time
• Cost sharing may apply to the patient

Get consent before you start APCM services. You only need to get consent once.

• Conduct an initiating visit (paid separately) for new patients. You don’t need to conduct this visit if you or another provider in your practice have:
• Seen the patient within the past 3 years
• Provided another care management service (APCM, CCM, or PCM) to the patient within the past year

The Medicare Annual Wellness Visit (AWV) may qualify as the initiating visit if the provider that will be responsible for providing APCM care performs the AWV

• Provide 24/7 access and continuity of care, including:
• 24/7 access for your patients or their caregivers with urgent needs to contact you or another member of the care team
• Real-time access to the patient’s medical information
• The ability for the patient to schedule successive routine appointments with a designated member of the care team
• Care delivery in alternative ways to traditional office visits, like home visits or expanded hours
• Provide comprehensive care management, including:
• Systemic needs assessments (medical and psychosocial)
• System-based approaches to ensure receipt of preventive services
• Medication reconciliation, management, and oversight of self-management
• Develop, implement, revise, and maintain an electronic patient-centered comprehensive care plan.
• The care plan must be available within and outside the billing practice, as appropriate, to individuals involved in the patient’s care
• Members of the care team must be able to routinely access and update the care plan
• You must also give a copy of the care plan to the patient or caregiver
• Coordinate care transitions between and among health care providers and settings, including:
• Referrals to other providers
• Follow-up after an emergency department visit
• Follow-up after discharge from a hospital, skilled nursing facility (SNF), or other health care facility

Coordination of care transitions must include:

• Timely exchange of electronic health information with other health care providers
• Timely follow-up communication (direct contact, phone, or electronic) with the patient or caregiver within 7 days of discharge from an emergency department visit, hospital, SNF, or other health care facility, as clinically indicated
• Coordinate practitioner, home-, and community-based care. You must provide ongoing coordinating communication and documentation on the patient’s psychosocial strengths, functional deficits, goals, preferences, and desired outcomes from practitioners, home- and community-based service providers, community-based social service providers, hospitals, SNFs, and others.
• Provide enhanced communication opportunities. You must:
• Offer asynchronous, non-face-to-face consultation methods other than the phone, like secure messaging, email, internet, or a patient portal
• Be able to conduct remote evaluation of pre-recorded patient information and provide interprofessional phone, internet, or electronic health record (EHR) referral services
• Be able to use patient-initiated digital communications that require a clinical decision, like virtual check-ins, digital online assessment and management, and evaluation and management (E/M) visits (or e-visits)
• Conduct patient population-level management. You must:
• Analyze patient population data to identify gaps in care
• Risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients
• Measure and report performance, including assessment of primary care quality, total cost of care, and meaningful use of Certified EHR Technology (CEHRT). You can either:
• Report the Value in Primary Care MIPS Value Pathway (MVP). You’ll report performance starting in 2026 for CY 2025.
• Participate in a Medicare Shared Savings Program Accountable Care Organization (ACO), Realizing Equity, Access, and Community Health (REACH) ACO, Making Care Primary model, or Primary Care First model.

Can Auxiliary Personnel Provide APCM Services?

Auxiliary personnel can provide APCM services incident to the professional services of the provider who bills the initiating visit (if required) and associated APCM services. APCM is a designated care management service, and auxiliary personnel will work under general supervision.

Auxiliary personnel means individuals who are supervised by physicians or other billing providers to perform services incident to professional services of the provider. They:

• Can be employees, leased employees, or independent contractors of the billing provider
• Must not have been excluded from Medicare, Medicaid, or other federally funded health care programs by the Office of the Inspector General or had their Medicare enrollment revoked
• Must meet any applicable requirements to furnish “incident

Where Can I Get More Information?

• To learn more about APCM services, visit the CY 2025 Physician Fee Schedule Final Rulewebpage
• If your patient would like to learn more about APCM services, they can visit the Advanced Primary Care Management serviceswebpage