Effective January 1, 2025 | CMS Physician Fee Schedule | APCM HCPCS G0556–G0558

APCM G0556–G0558 Monthly Bundle Rules

Q: Can APCM and CCM be billed in the same patient-month?

No. Professional guidance describes APCM as a bundle that includes CCM elements, so billing APCM and CCM for the same patient in the same calendar month creates duplicative payment risk.

Q: Can APCM and TCM be reported together after discharge?

No. CMS lists transitional care management as part of APCM's bundled elements. If you bill APCM for a month, you should not also bill TCM for that same patient-month.

Q: Do APCM elements have to happen every month?

CMS states you must be able to provide APCM elements and complete them when clinically appropriate, but not every element is required every month. Documentation should reflect what was delivered for that patient-month.

Q: Does APCM require time tracking?

APCM is non-time-based. Risk shifts from minute thresholds to proving you met APCM program requirements such as consent, care planning, access, transitions, and population management.

Q: Are QMB patients exempt from APCM cost sharing?

Yes. G0558 is defined by QMB status and federal law prohibits billing QMB beneficiaries for Medicare cost sharing. Safeguards must prevent statements or collections from QMB patients.

When you bill APCM for a patient-month, the overlapping CCM/PCM/TCM and bundled digital communication services generally must stay off the claim for that same month.

Last updated: December 18, 2025

For: Practice owners, billing managers, compliance leads, care management operators

How to use this page: Operational compliance guide based on public CMS and professional guidance. Not legal advice.

Regulatory Snapshot

One-Sentence Thesis

APCM is a once-per-calendar-month bundle; billing APCM means you generally cannot bill overlapping monthly care-management or bundled digital communication codes for that patient-month.

Why This Is Risky

Stacking APCM with CCM/PCM/TCM or bundled communication codes invites duplicative-claims risk, denials, and recoupment as automated APCM edits roll out.

Scope & Audience

Medicare PFS billing teams
Medicare Advantage plans mirroring CMS logic
Operational compliance leaders

Overview

CMS created Advanced Primary Care Management (APCM) as three monthly HCPCS G-codes (G0556, G0557, G0558) effective January 1, 2025. CMS frames APCM as a bundle that combines elements of existing care management services (CCM, PCM, TCM) and certain communication technology-based services (virtual check-ins, remote evaluations of pre-recorded patient information, interprofessional consultations). APCM is non-time-based, shifting risk away from minute logs and toward proving you met program requirements like consent, access, care planning, transitions, population management, and performance measurement.

Key takeaway in one sentence: If you bill APCM (G0556–G0558) for a patient in a calendar month, do not also bill overlapping monthly care-management services or bundled digital communication services for that same patient-month.

Core Rule: What CMS Requires to Bill APCM

What APCM Is

CMS states APCM “combine[s] elements of several existing care management and communication technology-based services.” AAFP expands the bundled set to include CCM, PCM, TCM, interprofessional consultation codes, online digital E/M codes, and specific HCPCS virtual check-in/remote evaluation codes.

Frequency and Unit of Service

CMS: APCM may be billed once per patient per calendar month.
AAFP: Monthly only; one clinician reports APCM per patient per month.

Treat the calendar month as the ledger. Concurrency mistakes happen when programs use rolling 30-day windows instead of patient-month decisions.

The Three Code Levels

G0556: Base APCM requirements with a primary-care focal clinician directing clinical staff.
G0557: G0556 requirements plus two or more chronic conditions meeting CMS’s duration/risk standard.
G0558: G0556 requirements plus QMB status and the same chronic condition standard.

APCM Is Non-Time-Based

APCM removes minute thresholds. Documentation shifts to program elements--consent, access, care planning, transitions, population management, performance measurement--rather than time logs.

What CMS Requires

Patient consent (disclosing one-provider-per-month and cost-sharing expectations).
Initiating visit logic with CMS exceptions; AWV may qualify in some cases.
24/7 access and continuity processes.
Electronic, shareable care plan.
Care transitions coordination with timely follow-up (within 7 days when clinically indicated).
Population-level management and performance measurement (reporting begins in 2026 for CY 2025 performance).
Auxiliary personnel may furnish services incident to under general supervision.

Overlap Rules: What Cannot Be Billed in the Same Patient-Month

APCM replaces billing for its bundled components in the same calendar month. Guidance from AAFP and NACHC states clinicians should not bill APCM and the bundled services together for the same patient-month.

Do-Not-Bill-With-APCM Set

CCM family (e.g., 99490/99439 and complex CCM).
PCM family (codes identified by AAFP as included in APCM).
TCM (99495–99496).
Bundled digital/communication services (virtual check-ins, remote evaluation of pre-recorded information, interprofessional consultations, online digital E/M codes listed by professional guidance).

What May Be Concurrent

Secondary guidance notes some programs may co-occur with APCM if requirements are independently met and effort is not double-counted (e.g., BHI, CHI, PIN, RPM, RTM, psychiatric CoCM). Two cautions:

Documentation must prove independent work, not repackaged APCM tasks.
Medicare Advantage and commercial payers may impose stricter edits; verify policies.

Common Failure Patterns and Traps

Trap 1: CCM + APCM

Billing CCM because minutes were met and also billing APCM for the month. APCM is designed to replace monthly time-based care management billing.

Trap 2: TCM + APCM

Billing TCM after discharge while also billing APCM. TCM is explicitly included in APCM’s bundle definition; choose one for the patient-month.

Trap 3: “Documentation-Light”

Treating APCM as time-free and under-documenting. APCM shifts documentation to program elements and plausibility, not minutes.

Trap 4: Tiering by Problem List Length

Billing G0557/G0558 because the diagnosis list is long without validating CMS’s chronic-condition duration/risk standard.

Trap 5: Billing QMB Cost Sharing

G0558 is QMB-defined. Billing QMB beneficiaries for cost sharing violates federal protections and triggers sanction risk.

Why These Behaviors Are Non-Compliant

Bundling and duplicative payment: APCM includes CCM/PCM/TCM elements and certain communication technology services. Billing APCM plus a component service for the same month double-charges by definition.
Monthly unit-of-service integrity: APCM is once per calendar month. Stacking multiple monthly management codes in a patient-month breaks the unit of service and is a target for automated edits.
Consent expectations: APCM consent discloses one-provider-per-month payment, reinforcing exclusivity and primary-care accountability.
Attestation and plausibility: Billing APCM attests the descriptor requirements were met. Records must show APCM-level services occurred for that patient-month.

Edge Cases and Clarifications

Month-to-month switches: CCM one month and APCM the next is allowed, but consent is separate for each program.
Elements every month? Not required. You must maintain the ability to deliver all elements and complete them when clinically appropriate.
Initiating visit: Required for “new” patients with CMS exceptions (seen in past 3 years or received another care management service in past year); AWV may qualify in some cases.

Billing timing within month: APCM may be billed at any point during the calendar month; billing early can preclude CCM/TCM that month.
Partial months: CMS does not create a partial-month APCM concept. If you cannot support APCM elements for the patient-month, do not bill APCM.
Concurrency with other programs: Co-occurring services (e.g., BHI/CoCM) must meet independent requirements and avoid double-counting effort; payer edits may vary.

Forward-Looking Changes Already Finalized for 2026

CMS finalized optional APCM add-on codes for complementary behavioral health integration or psychiatric CoCM (G0568, G0569, G0570) for CY 2026. These add-ons are billed when the APCM base code is reported by the same practitioner in the same month.

APCM remains the base monthly layer; add-ons attach to APCM rather than reintroducing parallel monthly stacks.
Design 2025 workflows so APCM can serve as the foundational patient-month program for future add-ons.

Operational Signal

CMS is moving toward larger units of service with practice capability requirements. APCM is non-time-based and built for general supervision, making it compatible with scalable team-based care.

Future-proof by building APCM first, then layering behavioral health add-ons and other services that do not conflict with APCM’s bundle.

Practical Implications for Practices

Convert APCM from “a billing code” to “a monthly operating model.”
Create a patient-month exclusivity gate so APCM suppresses overlapping CCM/PCM/TCM and bundled digital communication codes.
Standardize tiering logic on CMS chronic-condition criteria for G0557/G0558, not problem-list length.
Treat consent as a first-class artifact with one-provider-per-month and cost-sharing disclosure.

Keep the care plan electronic, maintainable, and shared with patient/caregiver.
Implement discharge follow-up workflows that meet the “within 7 days when clinically indicated” expectation.
Build QMB detection into intake and billing to prevent prohibited cost-sharing for G0558.
Produce a month-end APCM note summarizing interactions, care plan updates, coordination events, and transition follow-up.

Planning Checklist

Patient-Month Guardrails

Build a patient-month ledger that locks the billable choice.
Implement internal edits: APCM blocks CCM/PCM/TCM and bundled digital communication codes the same month.
Enable QMB protections before statements or collections run.

Eligibility & Evidence

Tier rules: G0557 requires two+ chronic conditions meeting CMS duration/risk; G0558 requires QMB plus those criteria.
Consent capture and retention with cost-sharing and exclusivity disclosures.
Initiating-visit logic with audit evidence.

Documentation Outputs

Electronic care plan that is maintainable and shareable.
Discharge follow-up proof within 7 days when indicated.
Month-end APCM note summarizing patient interactions and coordination events.

How This Fits the Bigger CMS / Payer Story

APCM moves primary care toward larger units of service with capability requirements, informed by CPC+ and Primary Care First models.
Design choices emphasize program-level accountability: non-time-based, electronic care plans, transitions, population management, and performance measurement.
CY 2026 adds behavioral health add-ons to APCM rather than encouraging parallel monthly stacks, signaling CMS’s trajectory toward bundled primary care.

Operational Interpretation

CMS wants fewer minute-based “billing games” and more defensible primary-care operating models. Practices that treat APCM as the base spine--and layer compliant add-ons--will be more resilient to payer policy shifts.

How FairPath Enforces APCM Boundaries

Patient-month rules engine prevents APCM from becoming billable when overlapping CCM/PCM/TCM or bundled digital communication services are selected.
Tiering logic tied to CMS chronic-condition standard and QMB status for G0557/G0558.
Consent gates with one-provider-per-month and cost-sharing disclosures.

QMB safeguards block prohibited cost-sharing statements and collections.
Automation produces month-end defensibility artifacts: care plan updates, coordination events, communications, and transition follow-ups aligned to the billed month.
Goal: keep the claim and record in lockstep under payer review.

FAQ

1

Can we bill APCM and CCM in the same month if we meet CCM minutes?

No. AAFP states APCM is a bundle and you cannot bill both APCM and the bundled services (example: APCM and CCM) for the same patient in the same month.

2

Can we bill APCM and TCM in the same month because the discharge work is real?

AAFP states APCM, CCM, and TCM may not be billed by the same clinician for the same patient in a month; choose which service to report.

3

Do we have to do every APCM element every month?

No. CMS and AAFP state not all elements are required each month, but you must complete elements when clinically appropriate and maintain the ability to provide all elements.

4

What are the most audit-sensitive APCM requirements?

Consent, initiating visit logic, care plan maintenance and sharing, transitions follow-up, and tier justification (two+ chronic conditions and QMB status for G0558).

5

Does cost sharing apply to APCM? What about QMB?

APCM consent must disclose that cost sharing may apply. QMB beneficiaries cannot be billed for Medicare cost sharing; CMS emphasizes this applies to both Original Medicare and Medicare Advantage.

References

Primary Sources (CMS)

Advanced Primary Care Management Services (APCM) requirements and billing rules (page last modified May 12, 2025).
CY 2025 Medicare Physician Fee Schedule Final Rule Fact Sheet (APCM overview, non-time-based structure, policy intent).
Prohibition on Billing Qualified Medicare Beneficiaries (MLN Fact Sheet, September 2025).
Qualified Medicare Beneficiary Program billing protections overview.
MM14315 CY 2026 PFS Final Rule Summary (APCM behavioral health add-on codes G0568–G0570).
CY 2026 Medicare Physician Fee Schedule Final Rule fact sheet (BHI/CoCM add-ons for APCM).

Secondary Commentary

American Academy of Family Physicians (AAFP): Coding for Advanced Primary Care Management (code families included in APCM, bundling logic, operational FAQs).
National Association of Community Health Centers (NACHC): APCM Reimbursement Tip Sheet (overlap statement and co-occurring service considerations).