CMS PFS Final Rule + QPP Guidance

APCM end-of-year reporting (2026): what you actually submit, when you submit it, and how to stay defensible

Advanced Primary Care Management (APCM) has a performance measurement and reporting requirement, but it is not a patient-by-patient “APCM packet” mailed to Medicare. Reporting is practice or clinician-level through QPP (for MIPS-eligible clinicians) or through participation in certain CMS models.

Last updated: January 19, 2026

For: Practice owners, billing managers, compliance leads, primary care ops teams

Scope: Medicare APCM (G0556–G0558), QPP submission, and 2026 reporting readiness

How to use this page: This is an operational compliance guide based on publicly available CMS sources. It is not legal advice. Use it to update workflows, reporting readiness, documentation standards, and audit response posture.

Regulatory Snapshot

Reporting requirement

Performance measurement and reporting is an APCM service element.

Primary pathway

MIPS-eligible clinicians can satisfy via the Value in Primary Care MVP (reporting begins 2026 for the 2025 performance year).

Submission window

QPP data submission for the 2025 performance year runs through March 31, 2026 at 8:00 PM ET.

Alternative pathways

Model participation may satisfy reporting (MSSP ACO, ACO REACH, Making Care Primary, Primary Care First).

Operational focus

Keep electronic care plan access and distribution, consent, contacts, transitions, community coordination, and population health evidence audit-ready.

End-of-Year Reporting Requirements for APCM

One key aspect of APCM is performance measurement and reporting. Unlike some programs where you might submit patient-level packets, APCM’s reporting is done at the practice or clinician level through existing Medicare quality reporting channels. In fact, CMS explicitly includes “measure and report performance” as a required service element of APCM. This means that practices must participate in quality reporting – for most, this will be via the Medicare Quality Payment Program (QPP). If you are a MIPS-eligible clinician, CMS has indicated you can meet the APCM reporting requirement by submitting the Value in Primary Care MIPS Value Pathway (MVP) starting in 2026 (for the 2025 performance year)^[1]. Clinicians who are participating in certain alternative payment models (for example, a Medicare Shared Savings Program ACO, ACO REACH, the Making Care Primary model, or Primary Care First) can fulfill the performance measurement element through those programs instead. In short, there is no need (or way) to mail Medicare an “APCM packet” for each patient – instead, you report aggregate quality data through QPP or your model sponsor.

Timing: The performance year for MIPS runs on a calendar year, and the data submission window is in the first quarter of the following year. For example, for the 2025 performance year, you would submit your MIPS (or other model) data by March 31, 2026 at 8:00 PM ET^[2]. This is the same timeline as traditional MIPS reporting. CMS opens the QPP portal for data entry in January, and you have until the end of March to upload and finalize your quality measure data for the previous year. After that deadline, no changes can be made, so it’s important to review and validate your data before submission^[3].

Operational Considerations: APCM’s reporting requirement means you should be prepared with the necessary evidence and data when it’s time to report. Many practices will choose the Value in Primary Care MVP reporting pathway, which focuses on primary care quality and cost measures. It’s wise to ensure throughout the year that you are capturing the data needed for those measures (e.g. clinical quality measures outcomes, improvement activities, etc.). The actual submission can be done in a few ways – directly via the QPP portal, through a certified registry or health IT partner, or by your ACO or model if they report on your behalf. You will choose the reporting pathway that fits your situation; the responsibility for submitting the data remains with your practice, not with any vendor tool.

How a Tool Like FairPath Helps: FairPath serves as the system of record for all the operational activities that underpin APCM. Throughout the year, it captures and time-stamps the key evidence you’ll want on hand when reporting and if you ever need to defend your performance. This includes things like care plan versions, patient communications (call logs, messages), follow-ups on transitions of care, community resource coordination notes, and so on. Having this information organized is invaluable – not because you send it all to CMS at year-end (you don’t), but because if you are ever audited or need to verify your work, you can produce a clear record. Remember, CMS requires that the APCM care plan be maintained electronically and made accessible to the care team and the patient^[4]. FairPath ensures you meet that requirement by housing an electronic patient-centered care plan that the whole team can view, update, and share with the patient as needed. All of the other APCM service elements likewise generate documentation (e.g. consent forms, follow-up logs), and FairPath keeps those organized per patient.

Your Responsibilities: Even with a supportive platform, your practice retains control of choosing how to report and actually doing the reporting. FairPath does not directly submit data to CMS for you – instead, it equips you with the evidence and summaries you need. For instance, if you’re submitting via the QPP portal, you would pull the relevant quality measure data (some of which may be tracked in FairPath or your EHR) and enter it into the portal. If you work with a registry or an ACO, you’d use FairPath’s records to fill in any reports or attestations they require. CMS has noted that participating in models like MSSP ACO or Primary Care First can satisfy the APCM performance reporting element, so if you’re in such a model, your ACO might handle a lot of the reporting heavy lifting – but you still need to maintain your own records of what you did.

Such a packet isn’t something you send to CMS, but it’s a reference compilation that can greatly streamline the reporting process and bolster confidence during sales discussions (“we have all your APCM work packaged and ready for QPP submission and audit support”). It demonstrates that the system not only helps perform APCM services but also makes end-of-year compliance bulletproof.

Practitioner Responsibility and APCM Submission Roles

APCM does not change the fundamental accountability of the billing practitioner. You, as the clinician (or clinic) billing APCM, remain ultimately responsible for meeting all requirements and for maintaining the medical record. CMS is very clear on this point: APCM services must be billed by a physician or other qualified provider who “is responsible for all of [the patient’s] primary care and serves as the continuing focal point for all needed health care services,” and who has obtained the patient’s consent for APCM^[5]. In other words, the program is intentionally centered on the primary care provider who oversees the patient’s overall care. You can’t offload that accountability to a third party.

Because the billing practitioner is in charge, certain tasks – such as attesting that requirements are met and that care was appropriately managed – require clinician sign-off. For example, one APCM element is “comprehensive care management.” While your team and software can do a lot of work (calling patients, arranging services, etc.), ultimately a clinician needs to review the patient’s status and attest in the record that comprehensive care management has been provided for that month. Similarly, performance reporting and any attestation of data accuracy are the provider’s responsibility. If you’re submitting data to QPP, you (or your designated submitter) must certify its truthfulness; a vendor like FairPath can’t legally do that on your behalf.

That said, APCM services can be delivered by a team. CMS allows the use of auxiliary personnel to furnish APCM services on behalf of the billing practitioner, under the general supervision “incident to” rules. Auxiliary personnel could include nurses, care managers, medical assistants, community health workers, pharmacists, etc. – anyone on your team (or contracted by your practice) who is qualified and whom you supervise. They can perform much of the non-face-to-face work in APCM. In fact, CMS explicitly designates APCM as a care management service eligible for “incident to” billing under general supervision. This means, for example, your nurse care manager can follow up with a patient after a hospital discharge or help coordinate community resources, and those activities count toward APCM as long as they are done per your direction and within program guidelines. You, as the billing clinician, do not have to personally do every phone call or chart review – but you do need to supervise the process and ensure the work is documented properly.

It’s important to maintain clear boundaries of responsibility:

What the platform (FairPath) does: It captures and organizes the care management records – things like consent obtained, care plan updates, calls made, tasks completed – and can generate evidence summaries. It essentially automates the documentation and tracking of APCM activities. For instance, when your staff logs a care coordination call in FairPath, that record is timestamped and stored, forming part of the auditable trail. The platform can also flag if certain required elements have not been addressed for a patient in a given month (e.g., no care plan update or no follow-up after a transition), prompting your team to take action.
What you or your reporting partners do: The actual submission of data to Medicare (CMS) or any formal attestation has to be done by you (the provider) or an intermediary like an ACO or registry that represents you. FairPath does not directly interface with CMS to send your quality data or claims – that remains your responsibility. For example, if you use a registry for MIPS, you would export data from FairPath or your EHR and provide it to the registry; the registry then submits to CMS. If you are in an ACO, your ACO might aggregate performance data, but you’d use FairPath to ensure all your activities and outcomes are recorded for the ACO’s use. Crucially, FairPath will not perform the legal attestation or “click the submit button” for your QPP submission – that liability stays with the clinician or organization billing Medicare.

To put it simply, FairPath supports your work but doesn’t replace your role. CMS expects that the “billing practitioner is ultimately responsible for documentation”, even if some services are done by others^[6]. So if your practice contracts with an external care management service or uses internal staff, you need to ensure they document everything in FairPath (or your medical record system) so that you have the full picture. FairPath’s job is to make that documentation deterministic and easy to review – meaning every required piece of evidence is logged in a structured way, and nothing falls through the cracks. This spares you from having to reconstruct the story months later if you’re audited or when compiling your reporting data.

For example, if an auditor asked, “How did you meet the care transitions follow-up requirement for Jane Doe in March?”, you should be able to pull up Jane’s record in FairPath and see that she was discharged from the hospital on March 10th, that your staff called her on March 12th and discussed her medications and appointments, and that this call is documented (with date, time, staff member, and summary). You would then use that evidence to demonstrate compliance. FairPath provides the operational record, but you would be the one to present or explain it to auditors.

Tracking APCM Requirements: From “Pending” to “Fulfilled”

At first glance, APCM comes with a long list of service elements that need to be addressed (consent, care plan, 24/7 access, transitions, etc.). However, APCM is not a checklist where you must do every element every month for every patient. CMS explicitly states that you should complete the required elements when they are clinically appropriate for the individual patient, and that you do not have to provide all services in every single month^[7]. In other words, all of the service elements must be available and offered as needed each month, but you exercise clinical judgment on what each patient actually needs at a given time^[8]. This is an important point – it refutes the misconception that APCM is a rigid monthly protocol. Instead, it’s a flexible care model where you tailor the services to the patient’s needs while ensuring no required capability is neglected.

How to Operationalize This: It helps to think of the APCM requirements as categories of care activities that need tracking. A platform like FairPath will represent these as a requirement checklist tied to evidence in the patient’s record. For each APCM-enrolled patient, you might see statuses for each required element (consent, care plan, etc.) indicating whether it’s pending, in progress, or fulfilled for the current billing period. There are generally three types of requirement tracking:

Automatically Evidenced Items: Some requirements are straightforward and can be auto-validated by the system. For example, patient consent – once the patient’s consent for APCM is obtained and recorded, the system marks this as done (and it only needs to be done once, not every month). Similarly, the presence of an initiating visit (when required for new patients) can be checked from claims or encounter data. Another example is the existence of an electronic care plan for the patient; if the care plan is created in the system and meets the criteria (updated, shared appropriately), that requirement is considered met. Even 24/7 access and continuity can be evidenced by the practice’s protocols (e.g. if you have an after-hours call line or telehealth availability, and you’ve documented that in your procedures or patient agreement, that counts). These items don’t require someone to manually check them off each month – the system knows from the data if the condition is satisfied.
Workflow-Evidenced Items: These are activities that occur as part of your care management workflow, which the system can track when your team performs them. For instance, care transition follow-up is an APCM requirement: if a patient was hospitalized or visited the ER, you’re expected to follow up within a certain timeframe (usually 7 days) to coordinate care^[9]^[10]. FairPath can track this by generating a task when a discharge is detected (or when you log a transition), and then you document the follow-up call or appointment. Once you log the follow-up (with date and time), the system marks the “transition follow-up” element as fulfilled for that patient. Other examples in this category are referrals and community coordination – say you helped connect the patient with a community service or you liaised with a specialist; if you record that activity, it counts toward the “home- and community-based care coordination” element. Asynchronous communications (like secure messages or emails to the patient) can satisfy the “enhanced communication opportunities” element – if the system logs that you had a portal message exchange with the patient this month, that box gets checked. Essentially, these items are evidenced by doing – when your team does the work and documents it, the requirement is met.
Clinician Judgement Items: A couple of the APCM elements are broader, qualitative aspects of care – for example, “comprehensive care management” and “care coordination” (in the holistic sense, not just after specific transitions). These are not a single task but an ongoing process, so how do you mark them fulfilled? Typically, this is where a clinician’s attestation or signoff comes in. FairPath might compile all the pertinent activities (e.g. chronic condition monitoring, medication reconciliation, preventive care efforts, patient education encounters) and present them for the clinician to review. The provider would then attest that, yes, based on all the work done this month, the patient did receive comprehensive care management and coordination. This could be as simple as clicking an “Attest” button next to that requirement for the month, which then timestamps the clinician’s signoff. It’s a way of saying: after considering everything we’ve documented, I as the clinician affirm that we met the intent of those elements for this patient.

Let’s outline the specific CMS-defined service elements that you need to be prepared to evidence (noting which category they fall into):

Patient Consent: You must obtain and document the patient’s consent to participate in APCM (one time only). CMS expects a note that the patient was informed of what the service is, that only one practitioner can bill it per month, that they can stop anytime, and that standard cost-sharing applies^[11]^[12]. This is an automatically evidenced item once completed – the system will show consent “on file” with the date. If no consent, you cannot bill APCM for that patient.
Initiating Visit (if required): For new patients or those not seen in your practice in the last 3 years, an initiating visit (e.g. Annual Wellness Visit or office visit) is required before APCM services start^[13]. If the patient is established or had certain other care management services recently (CCM, PCM, etc.), this might be waived. The system can check your records for a qualifying visit. Once a visit is done (or if not needed), this requirement is fulfilled. Automatic, based on billing data/patient history.
24/7 Access and Continuity of Care: You must provide 24/7 access for urgent needs and ensure continuity (the patient can see a consistent care team)^[14]. Typically, practices meet this by having after-hours call coverage and letting patients know how to contact someone at any time. You also ensure patients can get routine appointments with their designated provider or team. In FairPath, this might simply be a static acknowledgment that your practice has these capabilities (perhaps verified during onboarding). There’s no monthly task, but it’s a standing requirement. If audited, you’d produce your policy (e.g., “We have a 24-hour call line and Dr. Smith or an on-call colleague is always reachable”). Marked as available once policy in place.
Comprehensive Care Management: This involves ongoing, systematic care management of the patient’s conditions – e.g. assessing medical, functional, and psychosocial needs; ensuring preventive care is up to date; medication reconciliation; and supporting the patient’s self-management^[15]^[16]. Many of these activities overlap with what you do in CCM or regular chronic care. To evidence it, you’d have documentation of things like care plan reviews, medication reviews, check-ins on whether the patient got their screenings, etc. FairPath might aggregate these actions. Ultimately a clinician confirms that the patient’s care was managed comprehensively that month (this is a judgment/attestation item – supported by data, but requires your signoff).
Patient-Centered Care Plan (Electronic): You need to develop and maintain a comprehensive care plan for the patient that is patient-centered (reflects their goals and needs in lay language), and it must be kept electronically, routinely accessible to the care team, and available outside the billing practice as appropriate (meaning you can share it with other providers)^[4]. Also, a copy of the care plan must be offered to the patient or caregiver^[4]. This is a cornerstone of APCM. FairPath addresses this by having an electronic care plan module where you input the patient’s problems, goals, interventions, and it tracks versions. It also records when you share or send the care plan to the patient (fulfilling the “copy to patient” requirement). As long as the care plan exists, is kept up to date, and distribution is documented, this element is met. (This one is partly automatic – the system ensures the care plan is in place – and partly workflow, since someone has to update and share the plan periodically).
Care Transition Coordination: Whenever the patient transitions between care settings – for example, hospital to home – the practice must ensure timely coordination and follow-up. CMS specifies making reasonable efforts to contact the patient (or caregiver) within 7 days of a discharge from a hospital, ER, or skilled nursing facility^[9]^[17]. You also should exchange relevant health information with the other providers (e.g., get the discharge summary, send over the care plan). In practice, FairPath can help by prompting a follow-up task whenever it’s notified of a hospitalization (some integrations might pull ADT alerts, or you manually log it). When your staff completes the follow-up (say, a call documented on a certain date), you mark that task done. The system then flags “Transition follow-up: fulfilled” for the month for that patient. The documentation (call notes, etc.) serves as evidence. If no hospitalization occurred, there’s nothing to do – this element is simply not applicable that month (and that’s fine).
Home and Community-Based Coordination: This element is about coordinating with other providers beyond the clinic – such as home health services, community social services, or caregivers. CMS expects ongoing communication among the medical team and community providers to address the patient’s psychosocial needs, functional deficits, etc., and that you document these communications and the patient’s goals/preferences in the record^[18]^[19]. For example, if your care manager spoke with the patient’s home caregiver or collaborated with an adult day program or arranged Meals on Wheels, those would be logged. FairPath might have a section to record “Community coordination” notes. Once logged (with date, who you coordinated with, summary), that requirement is considered fulfilled for that timeframe. It’s a workflow-evidenced item – if you did it, document it. If the patient didn’t need any community services that month, again, not every element must fire every month – but over time you should be touching on this as needed.
Enhanced Communication Methods: APCM requires you to offer patients alternative, asynchronous ways to communicate, not just phone calls. This includes secure messaging, email, portal communication, remote monitoring check-ins, etc.. Essentially, patients should have the opportunity to contact the care team electronically for non-urgent matters, and the practice should be able to do things like review a picture or video a patient sends (remote evaluation) or coordinate with other providers via e-consults. To meet this, most practices will use a patient portal or secure messaging platform. Evidence could be the existence of a portal (so availability is there), plus logs if such communications occurred. FairPath can log any digital outreach done through its platform (for instance, if a patient sends a message or if you conduct a portal E-visit). These get counted toward this element. If none occur in a month, that’s fine as long as the capability exists. The requirement is both capability (offer it) and utilization when needed.
Patient Population Management (Risk Stratification & Care Gaps): This is a population-level activity rather than patient-specific. CMS expects the practice to analyze its patient population data to identify gaps in care and risk-stratify the population using defined criteria (like diagnoses, claims, etc.) to target services appropriately^[20]. We will delve into this more in the next section, but from a requirement standpoint, you should have evidence that you are continuously doing population health management – e.g., reports or logs of care gap outreach, risk scores assigned to patients, and interventions taken. FairPath can generate a lot of this automatically (for example, by importing your patient list, assigning risk tiers, and prompting staff to address care gaps). The fact that these workflows are happening and documented (e.g., “Called high-risk patients who were overdue for breast cancer screening this month; closed 5 care gaps”) demonstrates compliance with this element.
Performance Measurement and Reporting: As covered earlier, you must measure and report on quality, cost, and EHR use. For MIPS clinicians, this means reporting the designated MVP (Value in Primary Care) starting with CY 2025 performance. For those in APMs, it means participating in the model’s quality measurement. In terms of evidence, your QPP submission receipt or reports could serve as proof that you did this. It’s not something done per patient, but the requirement exists at the practice level. FairPath’s role here is mainly to ensure you have all the data and artifacts needed to report successfully (e.g., data for quality measures) and to store any relevant reports. When it comes time to attest or submit, that happens outside FairPath (via QPP site or ACO process), but you’d note that it was done.

As you can see, every APCM element can be tied to some form of documentation or tracking. The goal is to shift from a “check-box” mentality to a living record of care. Instead of keeping a mental note or sticky note that “I think we did everything for Mrs. Jones this month,” you have a concrete trail: consent on file, care plan updated March 2, follow-up call after her ER visit on March 5 documented, two secure messages exchanged, etc. If any item is pending (say Mrs. Jones had a hospitalization on March 28 and by March 30 no one has reached out yet), the system would show that the transition follow-up is still pending and alert the team to complete it (even if slightly late, it should be done). Once completed, it flips to fulfilled.

Making the Implicit Explicit: An APCM tracking system essentially makes implicit care explicit. In traditional practice, you might naturally do many of these things – call a patient after a hospitalization, talk to a family member, refill meds, etc. But without a structured program, those might not all be documented or counted. APCM requires you to be deliberate and thorough in documenting these care management activities. This not only helps with billing compliance but genuinely improves care coordination (everyone on the team can see what was done and what wasn’t).

Such a feature not only helps the practice stay on top of the work (they can see at a glance what’s pending) but also gives peace of mind. In a sales scenario, demonstrating how a doctor could, at any time, open a patient’s APCM evidence profile and see exactly what has been done (and print it out for an auditor) is extremely reassuring. It shows that nothing is left to memory or chance – everything is tracked and retrievable.

Population Health in APCM: Risk Stratification and Care Gaps

APCM isn’t just about individual patient interactions; it also mandates population-level management as a core service element. In fact, CMS describes that practices must “analyze patient population data to identify gaps in care” and risk stratify the practice’s population using electronic data (diagnoses, claims, etc.) to target services^[20]. This requirement essentially brings principles of population health management and preventive care into the APCM model.

What this means: Your practice should be continually reviewing your entire patient panel to determine:

Which patients are at higher risk and may need more intensive management.
What care gaps (e.g. missing preventive services, uncontrolled chronic conditions, overdue follow-ups) exist, so you can address them proactively.

Importantly, CMS expects this to be a systematic process, not a one-off project. You should have a method (usually software-driven) to segment patients by risk and track gap closures as an ongoing workflow.

In practical terms, here is how FairPath interprets and implements population-level management for APCM:

Roster Import and Normalization: It starts with getting your patient roster into the system, ideally with relevant data like problem lists, claims histories, or utilization flags. FairPath will ingest your list of Medicare patients (likely from your EHR or billing system) and keep it updated. “Normalization” means it will reconcile duplicates, update demographics, and ensure all APCM-eligible patients are accounted for.
Automated Risk Stratification: Using defined criteria (often based on diagnoses, number of chronic conditions, recent hospitalizations, social factors, etc.), the system categorizes each patient into a risk tier. For example, you might have tiers like High Risk, Rising Risk, Moderate, Low. A patient with multiple chronic illnesses, hospital admissions, and perhaps socioeconomic challenges might be flagged High Risk. Another with one or two stable chronic conditions might be Moderate. CMS doesn’t prescribe a specific algorithm, but it expects you to use “defined diagnoses, claims, or other electronic data” as criteria. FairPath can use rules or even predictive modeling to do this. The key is that every patient ends up with a risk level that is regularly updated.
Care Gaps Identification: Based on guidelines and your quality measures, the system identifies care gaps for each patient. A “care gap” could be a preventive service (e.g., mammogram, colonoscopy, HbA1c test if diabetic) that is due or overdue, a missing vaccination, an unmanaged condition (e.g., no recent blood pressure reading for a hypertensive patient), or a needed follow-up after an event (like no post-discharge follow-up recorded). These gaps are logged and often presented as a work queue or task list for staff. For instance, FairPath might show that John Doe, a high-risk diabetic, hasn’t had an eye exam in over a year – prompting outreach.
Workflow to Close Gaps: The platform facilitates closing these gaps. Staff might get a daily or weekly list: “Patients due for diabetes foot exam” or “High-risk patients without a care plan review in 6 months.” They can then take actions – call the patient to schedule a visit, send a reminder, arrange a referral – and document the intervention. When the gap is resolved (e.g., the patient got the service or declined it appropriately), the system marks it closed and it becomes part of the record. For example, if a care manager calls and the patient schedules a screening, that call is logged. Once the screening result comes back, the gap is officially closed in the system.
Evidence of Population Management: All these gap closure activities roll up into evidence of the “population-level management” element. If an auditor asks, you could generate a report from FairPath showing, for instance, “Over Q1 2026, we identified 120 care gaps among our APCM patients and addressed 95 of them; here’s a list of what they were and the actions taken.” It demonstrates you are not just reacting to patients when they come in, but actively managing the health of your panel.

Crucially, this isn’t a separate project you do once a year – it’s baked into the monthly routine. Each month, new data might change a patient’s risk stratification (maybe a new diagnosis moves someone from moderate to high risk), and new gaps will open or be closed. APCM expects the practice to have an ongoing mechanism for this. The good news is that many primary care practices have already been moving toward such population health approaches under programs like PCMH (Patient-Centered Medical Home) or ACO participation. APCM formalizes it: you must do it and be able to show that you did.

CMS’s focus here is to ensure no patient falls through the cracks. By risk stratifying, you ensure your sickest or most vulnerable patients get more attention. By identifying gaps, you catch things before they become bigger problems (e.g., ensuring a patient gets a flu shot or a cancer screening on time, or following up after an ED visit to prevent readmission).

From a system design perspective, FairPath or any APCM-support tool should make this as automated as possible. As a user, you shouldn’t have to manually comb through spreadsheets to figure out who’s high-risk – the system should present you a dashboard. For example:

A chart or list of how many patients are in each risk tier, maybe with definitions (High Risk = 2+ uncontrolled chronic diseases plus hospitalization in last 6 months, etc.).
The ability to click on, say, “High Risk (25 patients)” and see who they are.
For each patient, key care gaps or actions needed might be listed right there.
Tracking over time: perhaps a monthly snapshot that you can export showing “In January, X% of our patients were high-risk; by June, after interventions, maybe that changed or certain gaps reduced.”

By incorporating these features, you make population health tangible. Many practices struggle with manually doing these tasks; showing that your solution automates it will resonate strongly. It also ties directly into the Value in Primary Care MVP measures (which likely include some population health metrics), so having this data well-organized helps in quality reporting as well.

In summary, risk stratification and care gap management in APCM is about being proactive. With the right tools, it becomes a seamless part of care – you’re always a step ahead, ensuring patients get what they need. And if you ever need to prove it, you have the data at your fingertips, e.g., “CMS states we must use data to target services; here is a report of our risk stratification and the targeted outreach we did”^[20]. This level of preparedness not only fulfills APCM requirements but ultimately leads to better patient outcomes, which is the real goal of these programs.

Dual-Eligible Patients, Code Selection, and APCM vs. CCM

APCM introduced three new HCPCS codes (G0556, G0557, G0558) to account for different patient complexity levels. Choosing the correct code each month is important to ensure you are billing compliantly and maximizing appropriate reimbursement. Here’s how the codes break down:

G0556 – APCM Level 1: For Medicare patients with one or zero chronic conditions^[21]. This is the lowest tier (simplest patients). Essentially, if a patient doesn’t have multiple chronic conditions, they can still receive APCM services under this code (for example, a relatively healthy patient who you’re mainly doing preventive care and coordination for). G0556 has the lowest payment rate (approximately $15-20 per month nationally).
G0557 – APCM Level 2: For patients with two or more chronic conditions that meet the chronic care criteria (expected to last 12+ months or until death, and pose significant health risk)^[22]. This aligns with the typical threshold for Chronic Care Management (CCM) – two or more chronic conditions. G0557 essentially includes everything in G0556 plus the fact that the patient has higher complexity by virtue of multiple conditions. The reimbursement for G0557 is higher (roughly $48-50/month, per Medicare Physician Fee Schedule, though exact payment varies slightly) because these patients presumably need more care management.
G0558 – APCM Level 3: This is specifically for Qualified Medicare Beneficiaries (QMBs) who have two or more chronic conditions^[23]. A QMB is a dual-eligible patient – someone on Medicare and Medicaid who qualifies for assistance with Medicare premiums and cost-sharing. In practice, G0558 is used for your dual-eligible patients with multiple chronic conditions. The requirements in terms of services are the same as G0557 (it “includes all G0556 requirements” as well), but CMS created a separate code because these patients often represent a high-need, high-cost population (and the payment for G0558 is significantly higher, around $107/month on average^[24]^[25]). The higher rate acknowledges the intensive work often needed for duals.

So, code selection is straightforward in principle: you assign G0556, G0557, or G0558 based on the patient’s status that month. If the patient is a QMB and has 2+ chronic conditions, use G0558. If not a QMB but has 2+ chronic conditions, use G0557. If they have fewer than 2 chronic conditions, use G0556. The code definitions make clear you only bill one of these per patient per month, and each code’s criteria must be met^[22]. CMS also explicitly notes that APCM is per calendar month per patient – you cannot bill more frequently, nor can two different providers bill APCM for the same patient in the same month^[11].

Dual-eligible considerations (QMBs): You might wonder, why a special code for QMB? One reason is that QMB status affects payment (because Medicaid covers their cost-sharing, etc.), but also QMB often correlates with socio-economic complexity. When FairPath (or your billing system) knows a patient is a QMB, it can flag that and suggest G0558 if the chronic condition count criterion is met. Some EHRs or billing systems might automatically switch to G0558 for dual-eligibles. However, it’s good for the care team to be aware too. QMB status can usually be determined from insurance info or eligibility checks. (Note: A Qualified Medicare Beneficiary is a person on Medicare who has low income such that their state Medicaid pays their Medicare Part B premium and any coinsurance/copays. Essentially, the patient should not be billed any cost-share – they’re “covered” by Medicaid for those. QMB is one of the Medicaid Medicare Savings Programs.)^[26]

APCM vs. other care management programs (CCM, PCM, TCM): Medicare has made it clear you cannot double dip on similar monthly care management services. Specifically, APCM may not be billed in the same calendar month as Chronic Care Management (CCM), Principal Care Management (PCM), or Transitional Care Management (TCM) by the same provider for the same patient^[27]^[28]. The reasoning is that APCM actually bundles many of the components of those services – it is meant to replace them with a simpler, unified code. For example, if you did a TCM service for a patient in January (because they were discharged from the hospital), you should not also bill APCM for January for that patient; you would choose one or the other. Similarly, if a patient qualifies for both CCM and APCM (say it’s early 2025 and you’re deciding which to do), you would generally choose APCM (assuming they consent and you meet those requirements) instead of CCM, because you can’t bill both for January on the same patient.

This “no overlap” rule means each patient, each month, can only have one care management program billing. The practice must choose which service to report for that month. As the AAFP and other coding authorities have summarized, you must decide between APCM, CCM, PCM, or TCM, etc., depending on which is most appropriate^[28]. If you happen to perform a TCM service (say the patient was hospitalized and you do a post-discharge visit within 14 days), you might bill TCM that month and skip APCM for that patient in that month. Or vice versa – maybe you forgo TCM and just count that work toward APCM (but then you wouldn’t bill the TCM code). The same logic applies to PCM (principal care management for one complex condition) – APCM level 2 or 3 essentially replaces PCM if you’re doing APCM, because APCM covers all conditions.

A special scenario: What if a patient is eligible for multiple programs? For instance, consider a dual-eligible diabetic with congestive heart failure:

They could qualify for APCM (2+ conditions, QMB -> G0558).
They also qualify for CCM (2+ chronic conditions).
And if they were just hospitalized, they qualify for TCM in the month after discharge.

Medicare’s rule is clear that you cannot bill CCM/PCM/TCM concurrently with APCM^[27]. So it’s a one-or-the-other choice. In many cases, APCM will be the preferred approach from 2025 onward, since it consolidates everything and tends to pay as well or better than separate codes (especially for duals or complex patients). But practices need to be aware of this to avoid inadvertent billing conflicts.

Ensuring correct code selection: FairPath can assist by flagging the relevant factors:

It can display if a patient is marked as QMB (so you know G0558 is in play).
It can show the chronic condition count on record (to see if they meet the 2+ condition criterion for APCM at Level 2/3).
It can also alert if a patient received other overlapping services. For example, if your billing system shows a TCM code was billed this month for the patient, FairPath might warn, “Patient had TCM this month – APCM cannot be billed concurrently^[27].” This helps prevent mistakes.
If you are in an ACO or other program that might alternatively cover care management, the system could note that too.

In terms of compliance, the onus is on the provider to choose the appropriate billing code. If two different providers mistakenly both bill care management for the same patient (e.g., an oncologist bills PCM and you bill APCM in the same month), Medicare will generally only pay one – usually the one that was processed first or is considered primary. It’s best to coordinate in advance to avoid that scenario (this is more of an issue in PCM vs APCM if a specialist is doing PCM). For your own services, just make sure internally that your billing staff knows to only submit one code per patient per month in this family of services.

CCM vs APCM – transitioning: Many practices have been doing Chronic Care Management (CCM) for eligible patients. With APCM, you might migrate those patients to APCM in 2025. One thing to highlight: APCM requires a new patient consent even if they were in CCM. CMS clarified that even if a patient already consented to CCM, APCM is a different program, so you must obtain consent specifically for APCM^[29]^[30]. This is a one-time administrative step. After that, you’d stop billing CCM and start billing APCM (e.g., code G0557). There’s no penalty for switching; just don’t do both at once.

TCM considerations: TCM (Transitional Care Management) is a single-month code after discharge with requirements like a face-to-face visit within 7 or 14 days. If you do that, you’d typically not bill APCM that month. Some EHR/billing systems might help track this, but FairPath could also have a feature to require an explicit selection each month for patients who had a hospitalization. For instance, at month’s end, for any patient that qualifies for TCM, present a choice: “Do you want to bill TCM or APCM for this patient for January?” This ensures staff consciously picks one, preventing an “accidental” double billing. The system could even suggest which is higher value or more appropriate (e.g., TCM might pay a bit more than APCM for a non-QMB patient but involves a face-to-face visit; APCM covers broader services but pays monthly; etc.). Usually if the discharge happened and you provided TCM services, billing TCM is appropriate for that month, then resume APCM the next.

This kind of advisor ensures maximal compliance and revenue capture. It shows prospective customers that using FairPath will simplify the complexity of juggling codes – the system will guide them to the correct billing each time. It’s a safety net against one of the main pitfalls in care management billing (which is accidentally overlapping services).

In summary, APCM code selection boils down to matching the code to patient complexity (and QMB status) and making a single choice per month among overlapping services. The model is “one patient, one care management code, per month.” By following the criteria for G0556/G0557/G0558 and being mindful of other programs, practices can optimize their billing and compliance. Systems like FairPath can greatly assist by automating the checks and prompts needed to get it right every time.

Audit Defensibility and Integrating APCM Documentation into the EMR

Whenever a new program like APCM comes along, practices worry (rightfully) about audits and compliance. APCM involves a bundle of services that aren’t all directly observable by a claim reviewer, so you must maintain solid documentation to defend your billing if audited. The good news is that CMS has effectively built the documentation requirements into the APCM service definitions. If you meet the APCM requirements, you will inherently have created an audit trail. Let’s break down what needs to be documented and how you can organize it.

Central Piece – The Care Plan: APCM is built around a patient-centered comprehensive care plan that is maintained electronically. CMS requires that this care plan be “routinely accessible to the care team,” be available “within and outside the billing practice as appropriate to individuals involved in the patient’s care,” and that a copy is provided to the patient or caregiver^[4]. This means your care plan can’t be a static paper in a folder – it needs to live in a system where your team can update and view it (and ideally where other providers, like specialists or hospitals, can receive it if needed). It should contain the patient’s problems, goals, interventions, and be kept current. Each time it’s updated, you ideally track the date/version. From an audit standpoint, you’d be expected to produce the care plan showing it was active during the service period and that it was shared with the patient. FairPath, acting as the APCM system, ensures that every care plan update is time-stamped and that there’s a log (e.g., “Care plan updated on X date by Y user, and emailed to patient on X date”). This directly addresses a major audit point. For example, if an auditor asks, “Show me the care plan for this patient for Q1 2026 and proof you gave it to the patient,” you could pull that up: the electronic file plus a record of distribution.

Documenting Each Service Element: Beyond the care plan, APCM elements generate their own artifacts:

Patient Consent: You need to have the consent on file. In practice that could be a signed form or a documented verbal consent. Auditors will want to see a note or form dated prior to or at the time of billing the first APCM month, stating that consent was obtained. FairPath can store a digital consent record (even a PDF of a signed form or an electronic checkbox with patient’s verbal consent date). This should include that the patient was informed about the nature of APCM and applicable info (one provider per month, etc.). For audit, that record is your proof. (E.g., “Consent obtained 1/3/2025, documented by Jane RN.” And indeed, CMS expects you to “document in the patient’s medical record that consent was obtained.”^[12])
Initiating Visit (if applicable): If required, you’d show evidence of that visit (e.g., a bill or note from the AWV or office visit that served as the initiating visit on, say, 2/10/2025). This is likely already in your EHR. You might tag it in FairPath just to note it’s done. In audit, you’d simply point to the visit note and billing code from your records.
24/7 Access and Continuity: This one’s a bit unusual to “document” each month – it’s more about having a policy. In an audit, you might show your clinic’s after-hours protocol or how patients are informed about reaching someone 24/7 (for example, a copy of your new patient welcome packet or a screenshot of your website where it says “Call this number after hours…”). Since this isn’t a billable event, auditors typically just want assurance that you had such access in place. You can keep those policy documents handy.
Comprehensive Care Management: To defend this, you’d rely on the collection of documentation of all the care management activities. There isn’t a single “Comprehensive care management form,” but rather your cumulative records (care plan updates, call notes, med rec notes, preventive care actions) demonstrate that you were managing the patient comprehensively. A clinician’s attestation note (like “I reviewed the care plan and confirm comprehensive care management provided this month”) can be a helpful summary in the record. In an audit, you might show several pieces: e.g., “Here are the care coordination notes, here’s the med reconciliation record after the hospital visit, and here’s our note that we discussed the patient’s goals and preventive needs – collectively showing comprehensive management.”
Care Plan (again): As above, you’d produce the care plan document. Notably, CMS expects typical care plan elements (problem list, goals, interventions, etc.) to be included^[4], so your care plan template should have those. Make sure it’s patient-friendly (auditors might note if it’s just jargon – patient-centered means understandable language).
Care Transitions Documentation: For any month you billed APCM and the patient had a hospital or ER event, you should have documentation of your follow-up actions. FairPath, for example, would have a call log or task completion record. Ideally, it includes date/time of contact, who spoke to the patient or caregiver, and a brief summary (checked meds, scheduled follow-up visit with PCP on X date, etc.). If you attempted contact and couldn’t reach the patient, that should be documented too (with multiple attempts if possible). Auditors will look for that timing – was it within 7 days? The expectation per CMS is “timely follow-up communication … within 7 calendar days of discharge, as clinically indicated.”^[9]^[17]. You want to show you met that. FairPath’s timestamp on the follow-up call note is perfect evidence. Also, any exchange of information (like if you received a hospital discharge summary or sent over the care plan to the specialist) should be in the record (e.g., a note “Received discharge summary from Hospital A on 3/11, reviewed and incorporated into care plan.”).
Community/Home Coordination: Here you want to have notes for any interactions outside the clinic. If the patient has a case manager or a community service, notes of those conversations or actions (e.g., “Referred patient to Meals on Wheels on 5/5; discussed with daughter the need for home PT on 5/20”) are your evidence. CMS wants to see you “coordinating receipt of needed services” and “document communication regarding the patient’s psychosocial needs, functional deficits, goals, etc., in the medical record.”^[18]^[31]. The italicized part is something they specifically call out – meaning if you talked to, say, an adult social services agency about the patient’s situation, you should write that down in the chart. FairPath can capture these as encounter notes or coordination logs. An auditor would be satisfied seeing those entries.
Enhanced Communication (Tech-based): If you use secure messaging or other digital communication, those exchanges should be logged. In many cases, the messaging system itself keeps a transcript (which you can export or print). If a patient sent a portal message and you replied about a care issue, that’s part of the record. If you did a “virtual check-in” (a brief phone or video snippet not tied to a visit), note it. Essentially, any non-traditional communication that substitutes for an in-person encounter can be an important part of the story of care. Keep those transcripts or summaries. FairPath might integrate messaging so that it’s automatically documented.
Population Management Activities: To the extent that this is audited (less likely at individual patient level, more at practice level), you’d show evidence of the systematic process – e.g., reports of risk stratification and lists of gaps addressed (as discussed earlier). If an auditor wanted to see that you’re doing what you attested (measuring quality, etc.), you might provide your internal dashboard printouts or registry data. Since performance reporting is required, the ultimate proof is that you submitted your quality data to CMS (which they will know). But you could also show your internal tracking that led to it.

Storing in the EMR: A practical question: what records “live” in your EHR (Electronic Health Record) vs in an external system like FairPath? Many practices use their EHR for clinical documentation, but an external system for care management workflow. To ensure nothing is lost, a common best practice is to periodically export a summary from the care management system and file it in the EHR. For example, some clinics generate a monthly APCM summary note or PDF per patient that contains all the key activities and updates for that month, and then they upload that PDF to the EHR as an attachment or note. This way, the EHR – which is the official legal medical record – contains a snapshot of all the care management done outside of regular visits. The user’s question specifically mentioned doing this with NextGen (an EHR): generating a “patient snapshot PDF” and attaching it to NextGen as the permanent record. This is indeed how many practices preserve program documentation while keeping the EHR as the canonical source of truth. It’s a smart strategy: if later you leave the program or switch vendors, your EHR still has the historical data of what was done.

FairPath can facilitate this by offering an export on demand. For instance, at the end of each month, you could click “Generate Monthly APCM Note” for each patient (or batch generate for all), and that produces a PDF with details like: updated care plan, dates of all contacts, who did what, etc. You then attach that in your EHR. Some systems might allow a more direct integration (writing a note into the EHR), but a PDF is universally acceptable. The key is consistency – do it every month or every quarter so the record is complete.

From an audit perspective, if all your APCM evidence is in FairPath and an auditor is reviewing your Medicare claims, they will ask for documentation. At that point, you can either give them access to the FairPath records or (more commonly) you’d produce those exported documents and any relevant EHR notes. Since many auditors are accustomed to looking at the EHR, having those summaries in the EHR can simplify the process: you just print from the EHR chart, and it’s all there. If not, you’ll print from FairPath – which is fine as well, just ensure you can produce it quickly.

Example Audit Scenario: Suppose Medicare (or a contractor) is auditing 5 patients for whom you billed APCM in Q2 2025. They will likely request documentation for those patients for April, May, June 2025. What you’d want to show for each patient is:

The care plan (as of that period) and evidence it was shared.
A log of all APCM-related contacts/communications in those months (calls, messages, etc., with dates and who did them).
Notes on any transitions or referrals handled in those months.
The consent (just once, if not already provided earlier).
Any relevant visit notes (if an initiating visit was in that quarter, for example).
Possibly your quality report submission (though usually they focus on clinical documentation, not the QPP submission in these audits).

If you have a single compiled “APCM audit packet” for each patient per month, that would be golden. It essentially packages the above into one document.

In closing, audit defensibility is about having contemporaneous documentation for every required service element. With APCM, every element (consent, care plan, calls, etc.) leaves a footprint that should be captured. FairPath’s role is to capture those footprints automatically during the care process, so that later you’re not scrambling to piece together evidence. By integrating these records either directly into your EHR or in easily exportable packets, you ensure that if anyone questions your APCM billing, you can provide a thorough record that substantiates the services billed.

Ultimately, this level of documentation not only protects you in audits but also improves care – it means nothing important falls through the cracks for the patient. When done right, APCM documentation isn’t just bureaucracy; it’s a narrative of better-coordinated, patient-centered care. And that’s something both CMS and practices can be happy about.

FAQ Section

What happens at the end of the year for APCM? Do we have to send something to Medicare?

No. APCM does not require a patient-by-patient packet; the end-of-year requirement is practice- or clinician-level performance measurement and reporting through QPP or through qualifying CMS models (MSSP ACO, ACO REACH, Making Care Primary, Primary Care First). MIPS-eligible clinicians can satisfy the requirement by reporting the Value in Primary Care MVP, beginning in 2026 for the 2025 performance year.

When is APCM reporting due?

APCM performance reporting follows the standard QPP timeline: the performance year is the calendar year, with submission in the following year. For example, the 2025 performance year data submission window runs through March 31, 2026 at 8:00 PM ET. There is no monthly APCM submission to CMS; documentation should be maintained throughout the year for reporting and audit readiness.

Does FairPath submit APCM data to Medicare for us?

No. The billing practitioner remains responsible for APCM compliance, reporting, and attestation. FairPath does not submit QPP data or attest on your behalf; it captures the underlying evidence in a structured, time-stamped way so you or your reporting partner can complete QPP or model-based submission.

Who is allowed to perform APCM work?

APCM services may be furnished by auxiliary personnel incident to under general supervision, including nurses, care managers, medical assistants, pharmacists, and other staff performing non-face-to-face APCM work under the clinician’s direction. The clinician remains responsible for oversight, medical decision-making, and attestation that APCM requirements are met.

Do all APCM requirements have to be completed every month?

No. CMS states APCM elements must be completed when clinically appropriate for the individual patient, and not all services must be furnished every month. The requirement is that APCM service elements are available and delivered as needed based on clinical judgment.

How are APCM requirements tracked from pending to fulfilled?

APCM requirements are best tracked as a checklist tied to evidence. Some items are automatically evidenced (patient consent, initiating visit, electronic care plan), some are workflow-evidenced (transition follow-ups, referrals, community coordination, asynchronous communications), and others require clinician judgment and attestation (comprehensive care management and care coordination).

What APCM elements must be documented?

CMS expects evidence of patient consent, initiating visit when applicable, 24/7 access and continuity, comprehensive care management, an electronic patient-centered care plan with patient access, care transition coordination with timely follow-up, home and community-based coordination, enhanced communication methods, population-level management, and performance measurement and reporting. Each element produces documentation that should be time-stamped and retrievable in the medical record.

How does APCM handle risk stratification and care gaps?

Population-level management is an explicit APCM service element. CMS expects practices to analyze population data, risk-stratify patients using diagnoses, claims, or other electronic data, and identify and address gaps in care through ongoing workflows that segment risk tiers, surface care gaps, and document interventions over time.

How does the system know if a patient is dual eligible and which APCM code to bill?

APCM code selection is driven by objective facts: G0556 is for patients with zero or one chronic condition, G0557 is for patients with two or more chronic conditions, and G0558 is for Qualified Medicare Beneficiaries with two or more chronic conditions. APCM is billed once per patient per calendar month, and FairPath can flag QMB status and chronic condition counts to support correct code selection.

Can APCM be billed in the same month as CCM or TCM?

No. APCM may not be billed in the same calendar month as CCM, PCM, or TCM by the same clinician for the same patient. Practices must choose one primary care management billing approach per patient per month when services overlap.

What actually lives in the EMR for APCM?

The electronic care plan is the core APCM artifact and must be maintained, routinely accessible to the care team, and shared with the patient or caregiver. Beyond the care plan, the EMR should contain or reference documentation of consent, communications, transition follow-ups, community coordination, and APCM-relevant interventions, often with monthly or on-demand APCM summary PDFs as the permanent legal record.

How do you defend APCM in an audit?

Audit defense is based on contemporaneous documentation. A defensible APCM record includes the care plan and distribution record, consent documentation, contact logs, transition coordination evidence, community coordination notes, and population-health interventions. Practices should be able to generate a patient-level APCM audit packet for any month showing what was done, when it was done, who performed it, and how it satisfies CMS requirements.

References Section

Primary sources

Medicare Part B (Noridian): Modifier and HCPCS Changes for January 2025, including APCM service elements. (Noridian Medicare)
National Association of Community Health Centers (NACHC): APCM Reimbursement Tip Sheet. (NACHC)
RHIhub Rural Health Information Hub: Advanced Primary Care Management overview. (RHIhub)

Secondary sources

American Medical Association advocacy update noting the 2025 performance year QPP submission timeline. (AMA)