Understanding Advanced Primary Care Management (APCM)

The move to APCM is designed to reward proactive, population-based care. While this removes the burden of time-tracking, it introduces new documentation challenges. To succeed, practices must be able to demonstrate that all 13 service elements are available.

The 13 Core APCM Service Requirements

APCM is defined by 13 core services that must be made available to patients. I've grouped them into three key areas for clarity.

1. Foundational Requirements

• Patient Consent. Obtain and document verbal or written consent. It must inform the patient that only one provider can bill for APCM monthly, that cost-sharing may apply, and that they can opt-out anytime.
• Initiating Visit. Required for new patients or those not seen in 3 years. A Medicare Annual Wellness Visit (AWV) qualifies.
• 24/7 Access. Patients or their caregivers must have round-the-clock access to a practitioner for urgent needs, with real-time access to their electronic medical record.

2. Comprehensive Care & Coordination

• Systemic Care Management: This includes systemic needs assessments (medical and psychosocial), medication reconciliation, and oversight of patient self-management.
• Care Transitions: Manage referrals and follow-ups after ED visits or hospital discharges. This must include electronic data exchange and patient contact within 7 days of discharge.
• Coordination with Other Services: Ongoing communication with home-, community-based, and social service providers to document patient goals, strengths, and deficits.
• Continuity of Care & Alternative Delivery: Patients must be able to schedule routine appointments with a designated team member and have access to care outside traditional office visits (e.g., home visits, telehealth).

3. Technology and Population Health

• Electronic Care Plan: Maintain a comprehensive, patient-centered care plan in an EHR that is accessible to the patient and all internal and external team members.
• Enhanced Communication: Offer asynchronous communication methods beyond the phone, such as secure messaging, email, or a patient portal.
• Population Data Analysis & Risk Stratification: Analyze population data to identify care gaps and risk-stratify patients to target services effectively.
• Performance Measurement: Report on primary care quality and cost, often through programs like MIPS Value Pathways or by participating in an ACO.

APCM vs. CCM: What's Changing?

APCM will replace Chronic Care Management (CCM) for many practices. The key difference is the shift from time-based billing to a service-based model. While many service elements overlap with CCM, the lack of a 20-minute time requirement simplifies clinical workflow but increases the importance of documenting service availability for audits.

Billing for APCM: Who and How?

According to CMS, auxiliary personnel can provide APCM services "incident to" the professional services of the billing provider, working under general supervision. This allows practices to leverage their entire care team, including care managers and MAs, to meet the APCM requirements without adding to physician workload.