Story by CCS Editor / September 12, 2024
As we approach 2025, The Centers for Medicare and Medicaid Services (CMS) is proposing a new addition to Care Management programs, Advanced Primary Care Management Services (APCM).
“For CY 2025, we are proposing to establish coding and make payment under the PFS for a new set of APCM services described by three new HCPCS G-codes. The proposed APCM services would incorporate elements of several existing care management and communication technology-based services into a bundle of services that reflects the essential elements of the delivery of advanced primary care, including Principal Care Management, Transitional Care Management, and Chronic Care Management.”
Under the addition of APCM, the three new HCPCS G-codes and their services will be:
Reimbursement: $10
Eligibility: 1 Chronic Condition, Seen in Last 3 Years
Service Requirements: Advanced primary care management services provided by clinical staff and 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, with the following elements, as appropriate.
Reimbursement: $50
Eligibility: 2 Chronic Condition, Seen in Last 3 Years
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, with the elements included in GPCM1, as appropriate).
Reimbursement: $110
Eligibility: 2 Chronic Condition, Qualified Medicare Beneficiary, Seen in Last 3 Years
Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary 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, with the elements included in GPCM1, as appropriate).
“This new coding and payment would better recognize and describe advanced primary care services, encourage primary care practice transformation, help ensure that patients have access to high quality primary care services, and simplify billing and documentation requirements, as compared to existing care management and communication technology-based services codes. The proposed codes also represent a step towards paying for primary care services with hybrid payments (a mix of encounter and population-based payments) to support longitudinal relationships between primary care providers and beneficiaries by paying for care in larger units of service, and also help drive accountable care. Physicians and NPPs in Shared Savings Program ACOs, and some Innovation Center models satisfy requirements for these codes.”
While the open comment period continues, Chronic Care Staffing is happy to have conversations with you and your organization about how to implement APCM in 2025 if desired.
