In 2025, CMS introduced Advanced Primary Care Management (APCM) as the latest remote care program. Unlike its predecessors, such as Chronic Care Management (CCM) and Remote Patient Monitoring (RPM), APCM is a move towards value-based payments and population-based care.
Rather than measuring remote care in billable time units, APCM requires practices to make a set of thirteen services available to patients. Patients do not need to use all or any of the services in a given month to be billable but must be able to access any of them when needed.
While APCM lifts the administrative burden of tracking time, practices need to ensure that they can document the availability of all of these services. APCM is not restricted to any specific specialty like Primary Care or Internal Medicine, but any practice billing APCM codes must be the primary point of coordination in managing care. If a cardiology or pulmonology group is taking over care planning and management for a patient, they can bill APCM.
So, what are the 13 service elements and how easy will it be for practices to demonstrate that they have these services available?
Onboarding and Access Elements
The first three elements should be relatively easy for any practice that currently offers CCM to provide, but documentation is critical. Without documentation of time-tracking, practices should expect that CMS will be looking for documentation on the service elements.
- Patient Consent: Patients must consent to the service and consent must be documented in their medical record.
- Initiating Visit: New patients or those who have not had a visit in three years must have an initiating appointment for APCM and that visit should be documented in their medical record.
- 24/7 Access: Patients must have 24/7 access to urgent care access with a care team/practitioner, similar to CCM requirements.
Chronic Care Management Elements
Since APCM will replace CCM for many patients, several of the required elements are the same service level requirements included in CCM. These elements must be documented in the EHR since there is no longer a time-tracking requirement.
- Continuity of Care: This ensures APCM patients have the continuity of care for routine appointments as required by CCM. The care coordinator should be noted in the EHR to demonstrate continuity of care.
- Alternative Care Delivery: This ensures that patients have access to care and preventative services beyond in-clinic visits. CMS did not specify exactly what must be available but provides a list of potential ways that practices can meet this requirement, including home visits, extended hours, telehealth, and/or non-traditional office visits. “Non-traditional office visits” is a broad statement and CMS could provide further requirements on this in subsequent years. This existing language means most practices providing CCM are already meeting this requirement.
- Comprehensive Care Management: This requirement ensures all APCM patients have access to core CCM services, including needs assessment, preventative services, medication reconciliation, and oversight of self-management. It is no longer required that patients receive a full 20 minutes of these services to be billable but they must have access to preventative care and practices should continue to document the CCM-type services that are provided.
Technology and Communication Elements
For a modern practice, the technology and communication elements are likely already available. As is true for all 13 APCM elements, what potentially makes them new and/or difficult is the need to document that they are available.
- Electronic Care Plan: Like current CCM requirements, practices must document and manage the care plan in an EHR.
- Care Transitions Coordination: ACPM providers don’t need to provide full Transitional Care Management (TCM) services but must be responsible for transitioning patients between healthcare settings and being the primary source of communication between providers about the transition. Transition notes should be documented to demonstrate the availability of this element.
- Ongoing Communication: This is another element similar to CCM requirements. While providers no longer need to track the exact time spent on communication between providers about the patient’s care, they must document that the communication is happening.
- Enhanced Communication Methods: Similar to alternate care, CMS did not prescribe specifics on what practices must provide, but rather general direction that they have digital communication options, such as secure messaging, email, or a patient portal. While office email may be sufficient to meet this in the short term, CMS could further clarify this element in the future.
Population Health Elements
The last three elements may be the most difficult for some practices to meet but also have vague language at the moment. CMS will likely provide more guidance and requirements on how to meet these going forward, but it would be wise for practices to begin documenting as much as possible on these elements.
- Population Data Analysis: CMS wants practices to be able to identify high-risk populations and provide interventions. With the current language, running reports that show at-risk populations may be sufficient, but there may be more guidance on specific interventions required at a later date.
- Risk Stratification: This element is similar to population data analysis and is also vaguely worded. The ability to run reports to show high-risk patients may be sufficient until CMS provides further clarification.
- Performance Measurement: CMS has indicated that it will provide more guidance on how to meet this requirement. MIPS reporting and shared savings programs for ACOs will meet the requirement for practices that participate in those programs.
A Movement Towards Value-Based Care
The APCM codes are a significant shift for CMS and a sign of what is to come in the future with population-based health and value-based care. While the idea of fixed payments for a set of services inherently lifts the administrative burden of time-tracking codes, it also introduces new documentation challenges.
Most EHRs will support many, but not all of the 13 elements so practices will need to document and report both in and outside of the EHR in the short-term to be prepared for potential audits. CMS has been explicit that APCM, like CCM, can be outsourced under general supervision, which can lift the documentation burden from under-resourced practices.
Does APCM make sense for your practice?
Billing APCM codes will replace CCM, but APCM can be billed concurrently with RPM. A combination of value-based and time-based codes may optimize care and reimbursement for many practices. If you are interested in understanding the potential reimbursement increase from adopting an APCM + RPM approach to your chronic care patients, download our 2025 Remote Care Billing Guide or set up a free consultation with one of our remote care experts.