CMS Finalizes APCM Codes for 2025: What it Means for Primary Care and Digital Health Companies
In a significant move to incentivize enhanced primary care delivery and management, the Centers for Medicare & Medicaid Services (CMS) have finalized the Advanced Primary Care Management (APCM) codes in the 2025 Medicare Physician Fee Schedule (the” 2025 Final MPFS” or the “Final Rule”).
These codes, proposed earlier this year as part of a broader commitment to expanding primary care management services, are intended to support practices transitioning toward value-based care (See our overview of the July proposal here for additional context).
CMS received a wave of largely positive feedback to its original proposal. Here’s a closer look at the APCM codes in the Final Rule and what they could mean for healthcare innovators and primary care providers.
1. Expanded Code Designations and Valuation Adjustments
CMS finalized the new HCPCS codes as G0556, G0557, and G0558, generally as follows:
G0556 (Level 1): APCM services for a patient with one chronic condition, may be provided by clinical staff and must be directed by a physician or other qualified healthcare professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month.
Approximate Reimbursement Rate: $15
Importantly, in response to stakeholder feedback, CMS increased the valuation of this Level 1 service code, boosting its payment to approximately $15 per month—up from the initially proposed $10. This change reflects CMS’s acknowledgment of the resources required for primary care management and may further encourage adoption of enhanced care management services for many, if not most, patients in a primary care practice.
G0557 (Level 2): APCM services for a patient with 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, may be provided by clinical staff and must be directed by a physician or other qualified healthcare professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month.
Approximate Reimbursement Rate: $50
G0558 (Level 3): APCM services for a patient who is a Qualified Medicare Beneficiary (QMB) with 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, may be provided by clinical staff and must be directed by a physician or other qualified healthcare professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month.
Approximate Reimbursement Rate: $110
2. Streamlined Requirements for Service Elements
The new codes aim to decrease administrative burden by simplifying the requirements for monthly services and billing. While practices must be capable of providing all 13 APCM service elements, not every element must be delivered each month. This flexibility allows practices to tailor services based on patient need rather than focusing on the number of minutes spent by clinicians on care management. The service elements are summarized below:
Patient consent
Initiating visit for patients not seen within 3 years
24/7 access to care team for urgent needs
Designated contact for continuity of care
Alternative options for care delivery
Comprehensive care management, including assessments, preventive services, and medication management
Electronic care plan accessible to patients and providers
Coordination of care transitions
Ongoing communication and coordination with community-based service providers
Enhanced opportunities for use of asynchronous non-face-to-face digital communications methods
Patient population analysis
Risk stratification
Performance measurement and meaningful use of CEHRT
3. A Shift Toward Seamless, Integrated Care through Technology
The final rule highlights CMS’ commitment to virtual care and digital communications technology as a component of APCM. By encouraging the use of a variety of communications technologies, practices will be better equipped to meet patients where they are. The Final Rule also creates new opportunities for digital health companies to support primary care practices in delivering proactive, data-driven care.
4. Balancing New APCM Codes with Existing Care Management Services
In response to concerns about overlap with existing Chronic Care Management (CCM), Principal Care Management (PCM), and Transitional Care Management (TCM) codes, CMS clarified that APCM services should not be billed concurrently with CCM, PCM, or TCM services. However, Remote Physiologic Monitoring and Remote Therapeutic Monitoring services are separately billable.
The Bottom Line
As CMS moves closer to its goal of having all Medicare beneficiaries in accountable care models by 2030, the APCM codes could set the stage for a new era in value-based care.
By supporting primary care practices in their transition to advanced primary care models with new reimbursement opportunities, CMS is signaling that innovative approaches to care that integrate innovative technology to enhance communication and reduce staff burden are essential to the future of healthcare delivery.
If you’re a digital health company looking to better understand how these new APCM codes will impact your business in 2025, our team at Nixon Law Group is here to help! Contact us today via this page.