Though the Centers for Medicare & Medicaid Services (CMS) has introduced another acronym into the Medicare mix, some physicians express optimism this particular one could help practices stay viable.
For Greg Fuller, MD, the newly introduced advanced primary care management (APCM) codes signal potential revenue for work he’s already doing – managing Medicare patients with at least one chronic condition.
The Keller family medicine physician encourages physicians to look into adopting the codes, cautioning those who have eligible patients yet ignore using them.
“You’re leaving a lot of revenue on the table,” said Dr. Fuller, past chair of TMA’s councils on socioeconomics and quality.
For those who can navigate the guidelines, the codes provide the potential for additional Medicare income with a more streamlined approach to billing than previously established care management codes.
The APCM codes made it into the final 2025 Medicare Physician Fee Schedule issued in November and took effect Jan. 1.
To help physicians better understand how to utilize them, TMA has readied an educational resource sheet and, as of this writing, is preparing a CME course, following one TMA created to explain the latest Medicare fee schedule (tma.tips/2025MedicareCME), to help guide physicians through the process. More information will be made available in TMA’s Physician Payment Resource Center (PPRC) (texmed.org/PaymentResourceCenter).
Despite overall concerns about Medicare physician payment, TMA said it “greatly appreciates that CMS continues to examine opportunities to strengthen and invest in primary care” in a Sept. 6 comment letter on the final schedule that made clear its support for the new codes (tma.tips/2025FinalScheduleLetter).
According to CMS, APCM services “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” (texmed.org/CodingWithCare).
The new APCM services, however, improve upon those prior iterations with one significant change: “Unlike existing care management codes, there are no time-based thresholds included in the service elements, which is intended to reduce the administrative burden associated with current coding and billing,” CMS said.
“Having to track the time of your phone call or writing in your notes how much time you were spending on the phone, it just started to get a little bit silly,” said Houston family physician Lindsay Botsford, MD, of the time-driven particulars of prior care management programs.
Implementing the codes requires physicians to incorporate 10 specific elements into the patient’s care plan, as CMS grouped them, including several related to documentation and assessing performance. Patients must sign a one-time consent form before APCM services can begin.
A physician billing for primary care should either use an APCM code or one of the previously-established codes, such as CPT codes 99490, 99439 or 99491 for chronic care management – but not both.
Some effort is needed for practices to conform to all the guidelines, Dr. Fuller cautions, including preparing required consent forms and making sure care coordination forms exist in a practice’s electronic health records system.
Practices using the Merit-Based Incentive Payment System or working with accountable care organizations, also should be familiar with the measurement and reporting requirements for the APCM codes, he added.
While encouraged by the program’s potential boost for practice viability, Drs. Botsford and Fuller also expressed concern about the cost-sharing condition required for some patients.
CMS’ guidance says “cost sharing may apply to the patient.”
TMA staff note that’s typically 20% following payment of the deductible but is contingent on whether the physician accepts the Medicare-approved amount as full payment, as well as whether CMS considers the physician to be participating, non-participating, or opted-out of Medicare.
TMA staff also point out payment for the three codes is dependent on the geographic practice cost indices as well as relative value units (RVUs), but they estimate a G0556 code would pay a physician practice about $15 per patient per month, a G0557 code would pay about $47 to $49 per month, and a G0558 code would pay in the $102 to $110 range.
Gary J. Sheppard, MD, chair of TMA’s Council on Socioeconomics, says it is still unclear whether Medicare Advantage plans will provide payment when physicians file claims using the new codes. He began exploring this with a few test cases to gauge reception from those plans before investing significant time and energy into making multiple claims.
“In larger group practices, this is going to definitely be a benefit for them, because they have the extra staff to complete the checklist of items, to coordinate it, to make sure everything’s done,” the Houston internist said.
While he observed smaller practices might be more challenged to meet the requirements, Dr. Sheppard notes the ability to fold some elements of the APCM plan into annual wellness visits makes it more manageable.
Troy Fiesinger, MD, the practice medical director at Village Medical’s Sugar Land primary care clinic, says the revenue could work out to be a difference maker in funding additional hires and growing practices’ capacity to care for patients.
“The way a lot of practices will think about this is, ‘Am I going to get enough revenue to hire someone to do the work? Or try to free up time with existing people to do the work?” Dr. Fiesinger said. “That’s going to be a practice-by-practice decision.”
Though Dr. Botsford’s practice operates with a variety of payment models, she sees the value of the APCM codes for those who use a fee-for-service model and still want to account for the work going into managing a patient’s long-term care plan.
“We saw recognition through the [primary care management] codes [of] the idea of asynchronous work that goes on for caring for patients in primary care,” the Houston family physician said. “Seems we’re learning some lessons and taking feedback from implementation of previous codes.”