APCM codes: G0556, G0557, and G0558

What APCM is

Advanced Primary Care Management is a monthly payment bundle Medicare started paying for on January 1, 2025. Three HCPCS G-codes bill it, split by patient complexity rather than by minutes. CMS built it by folding several services a primary care practice was already billing separately into one code: principal care management, transitional care management, chronic care management, interprofessional consultations, and the communication technology-based services such as virtual check-ins, remote evaluation of pre-recorded patient information, and e-visits.

The design point is the absence of a stopwatch. CCM pays only if the month reaches 20 minutes of documented clinical staff time. APCM pays for the month if the practice has the capability to furnish all 13 service elements and furnishes the ones the patient needs. CMS states in its FAQ that the elements provided depend on medical necessity and individual patient need.

The three APCM codes

For levels 2 and 3 the conditions must be expected to last at least 12 months or until the patient's death, and must place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. That is the same eligibility language CCM uses.

Payment figures are 2026 Medicare national averages, calculated from the CMS CY2026 Physician Fee Schedule Relative Value File (January release) at the standard conversion factor of $33.4009. Qualifying participants in Advanced Alternative Payment Models are paid at $33.5675. Locality rates differ because of the geographic practice cost indices. Cost sharing applies to APCM, except for Qualified Medicare Beneficiaries, who cannot be billed Medicare cost sharing at all.

One footnote worth knowing if you are searching CMS documents. The agency's own APCM FAQ misprints all three codes as G0056, G0057, and G0058, dropping a digit from each. The correct codes are G0556, G0557, and G0558, as printed in the HCPCS file and the CMS provider page.

The 13 service elements

These come from the HCPCS long descriptor for G0556, which every level shares. The practice must be able to furnish all of them for any patient in any month it bills, and furnishes the ones that are clinically appropriate.

1. Consent. Written or verbal, documented in the record, telling the patient the service is available, that only one practitioner can be paid for it in a calendar month, that they can stop at any time effective at the end of the month, and that cost sharing may apply.
2. Initiation during a qualifying visit for new patients or patients not seen within three years.
3. 24/7 access for urgent needs to the care team or practitioner, regardless of time of day or day of week.
4. Continuity of care with a designated care team member the patient can book successive routine appointments with.
5. Care delivered in alternative ways to the traditional office visit, such as home visits or expanded hours.
6. Comprehensive care management, including systematic medical and psychosocial needs assessment, a system-based approach to preventive services, and medication reconciliation and oversight of self-management.
7. An electronic patient-centered comprehensive care plan, developed, revised, and maintained, reachable inside and outside the billing practice, updatable by the care team, with a copy to the patient or caregiver.
8. Coordination of care transitions, including referrals and follow-up after an emergency department visit or a discharge, with timely electronic exchange of health information and follow-up contact with the patient or caregiver within 7 calendar days of discharge as clinically indicated.
9. Ongoing communication and coordination with other practitioners, home- and community-based service providers, social service providers, hospitals, and skilled nursing facilities, documented in the record along with the patient's psychosocial strengths, functional deficits, goals, and preferences.
10. Enhanced communication opportunities through asynchronous methods other than the telephone, such as secure messaging, email, or a patient portal.
11. Population data analysis to find gaps in care and offer additional interventions.
12. Risk stratification of the practice population using diagnoses, claims, or other electronic data, to target services.
13. Performance measurement on primary care quality, total cost of care, and meaningful use of certified EHR technology.

The CMS provider page groups these under ten headings, which is why some summaries say ten elements and some say thirteen. The descriptor itself lists thirteen.

Element 13 has a real reporting obligation attached. CMS gives two routes: report the Value in Primary Care MIPS Value Pathway, or participate in a Shared Savings Program ACO, an ACO REACH entity, Making Care Primary, or Primary Care First. A practice that meets none of those is not meeting the element.

Who can bill APCM

A physician or non-physician practitioner, meaning a nurse practitioner, physician assistant, or clinical nurse specialist, who is responsible for all of the patient's primary care and serves as the continuing focal point for all needed health care services. CMS notes the codes are primarily for primary care specialties such as general internal medicine, family medicine, geriatric medicine, and pediatrics.

Auxiliary personnel can furnish APCM services incident to the billing practitioner, under general supervision. RHCs and FQHCs can bill APCM and receive separate payment, with or without a qualifying visit, at the PFS non-facility rate.

The initiating visit is not the CCM initiating visit

APCM needs an initiating visit for new patients, but the lookback is three years, not one. CMS also waives it if you or another provider in the practice have furnished APCM, CCM, or PCM to the patient within the past year.

Level 2 through 5 office visits (99212 through 99215), the face-to-face visit inside TCM, the Annual Wellness Visit, and the IPPE all qualify, as long as APCM is discussed during the visit. The visit is paid separately.

What APCM cannot share a month with

APCM already contains these services, so billing both would pay twice for the same work. For the same patient in the same calendar month, you cannot report APCM alongside:

• Chronic care management (99490, 99439, 99487, 99489, 99491, 99437)
• Principal care management (99424 through 99427)
• Transitional care management (99495, 99496)
• Interprofessional consultations
• Remote evaluation of pre-recorded patient information
• Virtual check-ins
• Online digital E/M, the e-visit codes

When a patient qualifies for both APCM and CCM or TCM in a month, the practice picks one. That choice is the real decision APCM forces, and it is covered below.

New for 2026: the behavioral health add-ons

Starting January 1, 2026, CMS added three optional add-on codes for behavioral health delivered in the same month as APCM. They cannot stand alone; an APCM base code has to be reported in the same month.

APCM or CCM: the month-by-month math

Level 2 APCM pays $53.78 for a month with no minute threshold. A 20-minute CCM month pays $66.13. So on a per-month basis CCM wins, but only in the months you actually reach 20 minutes and can document them.

That is the trade. Take a panel of 100 patients with two or more chronic conditions. Billed as APCM level 2 every month, that is $5,378 a month with no time log. Billed as CCM, it is $6,613 a month if every patient hits 20 minutes, and most panels do not. A program billing 99490 on 60% of patient-months collects about $3,968. The break-even sits near 81% of patient-months reaching the threshold.

Two other differences matter more than the arithmetic. Level 1 APCM covers patients with one chronic condition or none, who are not CCM-eligible at all, so it opens a population that had no monthly code. And APCM removes the minute log, which is where most CCM programs actually bleed: not in unpaid claims, but in the staff time spent reconstructing time entries at month end.

Level 3 is the other consideration. Qualified Medicare Beneficiaries cannot be billed Medicare cost sharing, and G0558 pays $117.24 against $53.78 for the same clinical work at level 2.

Where APCM goes wrong

• Billing APCM and CCM for the same patient in the same month. They are mutually exclusive.
• Treating the capability requirement as optional. CMS expects the practice to be able to furnish every element for any patient in any month it bills, and says billing the code is an attestation that the descriptor requirements were met.
• Skipping the initiating visit for a patient last seen four years ago.
• Consent that omits the one-practitioner-per-month disclosure or the right to stop.
• Billing level 2 for a Qualified Medicare Beneficiary who qualifies for level 3.
• No route to the performance measurement element, meaning no MVP reporting and no participation in a qualifying model.
• A care plan that is not electronic, not shareable outside the practice, or never given to the patient.

How Pelica handles APCM

Three of the 13 elements are population problems rather than visit problems: analyzing panel data for gaps, risk stratifying the practice, and measuring performance on quality and total cost of care. Those are the elements a practice cannot fake at the patient level, and they are the ones that usually have no owner.

Pelica ingests claims, EHR, pharmacy, lab, and ADT into one record per patient, stratifies the panel, and surfaces the gaps as work rather than as a report. The Care Management copilot handles the post-discharge follow-up inside the 7-day window that element 8 requires, and the consent, care plan, and tier assignment sit on the same record so the month's claim is defensible. Customers run this across 350,000+ members.

Related terms

CCM CPT codes covers the time-based family APCM replaces, and the two cannot share a month. TCM CPT codes is the post-discharge service folded into the APCM bundle. The care management billing code reference lays the whole family out side by side, and G0402 is one of the visits that can initiate APCM.

Sources

• CMS: Advanced Primary Care Management Services
• CMS: Advanced Primary Care Management (APCM) Services FAQ
• CMS Medicare Learning Network: Chronic Care Management Services (MLN909188, June 2025)
• CMS: Federally Qualified Health Center (MLN006397, March 2026)
• CMS: CY2026 Physician Fee Schedule Relative Value Files (January release)