A three-physician internal medicine practice we work with billed chronic care management for about 90 patients in 2025. The care coordinator spent the last three days of every month reconciling time logs to make sure each patient crossed the 20-minute threshold for 99490. Some months a patient had 17 minutes and nothing was billable. In January the practice switched those patients to Advanced Primary Care Management, and the time logs went away.
APCM was introduced in the 2025 fee schedule and expanded in 2026 with three add-on codes for behavioral health. It is the most useful change to primary care payment in several years, and it is also easy to bill wrong, because it replaces a time threshold with a list of service elements the practice must actually provide. Here is how we set it up.
Key takeaways
- APCM has three monthly base codes set by the patient's condition count and QMB status (G0556, G0557, G0558), billed by one practitioner per patient per month with no time tracking.
- The trade for no minutes is a list of service elements the practice must actually have: consent, 24/7 access, a care plan the patient can see, transition follow-up and population-level review.
- New for 2026, G0568, G0569 and G0570 add collaborative care and general behavioral health integration on top of APCM in the same month, again without time thresholds.
- APCM excludes CCM, PCM, TCM and the communication technology-based services by the same practitioner in the same month; remote physiologic monitoring is not excluded.
- The 20 percent coinsurance applies every month except for QMB patients, so the cost sharing conversation belongs in the consent, not on the first statement.
The three base codes
| Code | Patient population | Billed |
|---|---|---|
| G0556 | Patients with one chronic condition or fewer | Once per calendar month, per patient, by one practitioner |
| G0557 | Patients with two or more chronic conditions expected to last at least 12 months and placing the patient at significant risk | Once per calendar month, per patient, by one practitioner |
| G0558 | Patients with two or more chronic conditions who are also Qualified Medicare Beneficiaries | Once per calendar month, per patient, by one practitioner |
The level is set by the patient's condition count and QMB status, not by what happened that month. A patient with hypertension and diabetes is G0557 every month whether the care team spoke to her for five minutes or fifty. That is the point of the code, and it is also why the service elements matter: CMS is paying for a practice that has the capability and delivers it, not for logged minutes.
The service elements the practice must provide
APCM requires the billing practitioner to be the patient's continuing focal point for all needed services and to provide, as appropriate, the full set of care management elements. These include patient consent, an initiating visit for new patients, 24/7 access to care and continuity with a designated team member, comprehensive care management including assessment and medication reconciliation, a patient-centered care plan available to the patient, management of care transitions with timely follow-up after discharges and emergency visits, coordination with home and community services, ongoing communication through means beyond the office visit, and population-level data analysis. The practice also must be assessed on performance, which for most practices means reporting the Value in Primary Care MIPS Value Pathway or participating in a qualifying alternative payment model.
Not every element happens for every patient every month. The requirement is that the practice has the capability and uses it as the patient's needs dictate. An auditor will ask to see the care plan, the consent, the after-hours access arrangement and the transition follow-up when one occurred. Build the documentation so those four things are easy to find.
The transition element is the one that most often has nothing behind it. It requires timely follow-up after an emergency department visit or a discharge, and a practice only knows about those events if something tells it. Ask your hospital or health information exchange for admission, discharge and transfer notifications, and route them to the care coordinator. A practice billing G0557 for 200 patients will see somewhere around 15 to 25 discharges or emergency visits a month in that group, and each one should show a documented contact within a couple of business days. If the notifications are not flowing, the element is not being met, and no amount of care plan documentation covers for it.
The "focal point" language also settles a question we hear from multi-specialty groups. A cardiologist managing heart failure and an internist managing everything else cannot both bill APCM for the same patient. The internist bills APCM; the cardiologist can bill principal care management for the heart failure if the PCM requirements are met, because the exclusion is by practitioner, not by patient. Put that rule in writing between the departments before the first claim, because the first practitioner to bill in a month holds the code and the second one denies.
Consent and the initiating visit
Consent must be obtained before the first month billed and documented in the record. It must inform the patient that only one practitioner can bill APCM for them per month, that they can stop at any time, and that cost sharing applies. That last point is where practices lose patients: the 20 percent Part B coinsurance applies to APCM, so a patient without supplemental coverage owes a small amount every month. Tell them at consent, not on the first statement. For G0558 the QMB status means the patient cannot be billed cost sharing, which is part of why the code is valued higher.
An initiating visit is required for new patients and for patients not seen within the prior three years. An annual wellness visit, an initial preventive physical exam or an E/M visit qualifies. Established patients seen recently do not need one.
The 2026 behavioral health add-ons
New for 2026 are three add-on G-codes billed in the same month as the APCM base code by the same practitioner.
- G0568: initial month of psychiatric collaborative care model services, based on CPT 99492.
- G0569: subsequent months of collaborative care, based on CPT 99493.
- G0570: general behavioral health integration, based on CPT 99484.
The service elements match the CPT codes they are based on. Collaborative care requires a behavioral health care manager, a psychiatric consultant who reviews the caseload and advises the treating practitioner, a registry, and validated rating scales such as the PHQ-9 tracked over time. General BHI requires an initial assessment, a care plan, and ongoing monitoring with a validated instrument. What differs from the CPT codes is time: the add-ons do not require the practice to track or document minutes. That removes the 70-minute and 60-minute thresholds that made 99492 and 99493 difficult for small practices, and the 20-minute threshold on 99484.
Do not bill the add-on and the underlying CPT code in the same month for the same patient. Pick the APCM path or the CPT path.
What cannot be billed with APCM
By the same practitioner for the same patient in the same month, APCM excludes chronic care management (99490, 99491, 99487, 99489, 99439), principal care management (99424 to 99427), transitional care management (99495, 99496), and the communication technology-based services such as virtual check-ins and remote evaluation of images. Remote physiologic monitoring is not excluded. A different practitioner in a different specialty can still bill PCM for a condition they manage, but the patient can have only one APCM practitioner.
The medical billing team at Revelrex runs the monthly APCM claim and the exclusion check for the practices we support, and our live training courses cover care management coding for coders and care coordinators.
Questions we hear
Can a nurse practitioner bill APCM?
Yes. Physicians, nurse practitioners, physician assistants and clinical nurse specialists can bill it, as long as they are the patient's focal point for primary care. Specialists generally should not, because the code describes comprehensive primary care.
Does the patient need to be contacted every month?
There is no monthly contact requirement in the code descriptor. The practice must be providing the service elements as needed. In our experience, practices that document at least one care management touch a month, even a portal message or a medication review, are in a stronger position if audited, and the patients notice the difference.
What happens to the patients who were on CCM in 2025?
They need APCM consent before the first APCM month, even though they consented to CCM. The consent elements differ (one practitioner per month, the right to stop, cost sharing), and the record should show the new conversation. Bill CCM for the last month of time-tracked service and APCM from the next calendar month; do not bill both for the same month. Patients who had fewer than 20 minutes of CCM time in most months are the ones who gain most from the switch, and patients who routinely needed 60 minutes or more of complex CCM may be better served staying on 99487 and 99489, so run the comparison per patient rather than moving the whole panel.
What to do this month
- Identify the panel: Medicare patients with an established relationship, sorted into the three levels using the problem list and QMB status from the eligibility response.
- Obtain and document consent, including the cost sharing conversation; for QMB patients note that no cost sharing applies.
- Build the care plan template and confirm it is shareable through the portal.
- Document the after-hours access arrangement and the designated team member in the practice's written policies, and confirm discharge notifications reach the care coordinator.
- Set a monthly claim run for the base codes and a check that no excluded code was billed the same month.
- For patients in collaborative care or BHI, add the appropriate add-on to the same claim.
- Confirm your MIPS Value Pathway registration or APM participation for the performance measurement element.
