CMS Opens the Door to More Virtual Care, Digital Health

New Advanced Primary Care Management codes will give providers more incentives to use virtual care and digital health to improve care management and coordination.

A new primary care model that allows providers to use virtual care and other technology to address patient care needs is getting the green light from the Centers for Medicare & Medicaid Services.

In the finalized 2025 Physician Fee Schedule unveiled last week, CMS included three new HCPCS codes for Advanced Primary Care Management. The codes, which take effect at the beginning of 2025, focus on physician interactions with patients at the time and place of their choosing and are billed monthly, rather than based on a specific number of minutes spent with a patient.

In a blog post earlier this year, Carrie Nixon and Kaitlin O’Connor of Nixon Gwilt Law said the new codes focus on specific activities by clinicians and using technology to address patient needs.

“The Advanced Primary Care Management (or APCM) HCPCS codes bundle elements of the existing Chronic Care Management (CCM) and Principal Care Management (PCM) codes set with Communications Technology-Based Services (CTBS) codes for virtual check-ins, remote evaluation of images, e-visits, and interprofessional consults to create what CMS refers to as an ‘enhanced care management’ bundle,” they wrote. “Unlike CCM and PCM services, the APCM codes are not time-based – meaning, care management services that do not meet the 20 or 30-minute requirements for CCM or PCM would be billable under APCM.”

Nixon and O’Connor also noted that CMS is expanding the rule to allow non-physician care providers, such as nurse practitioners and physician assistants, to order and bill for those services, as long as any practitioner who bills for those services “Intends to be responsible for the patient’s primary care and is the continuing focal point for all needed healthcare services.”

In a November 5 blog, Alexandra Shalom, senior counsel with the Foley & Lardner law firm, noted that because the new codes were designed to be consistent with existing codes for care coordination, providers need to be careful not to bill the new APCM codes alongside those overlapping codes. Examples of overlapping services include interprofessional specialist consults, remote evaluation videos and images submitted by patients, virtual check-ins and communications with patients through an online portal.

The three new codes are:

• G0556:  Level 1, for persons with one chronic condition.
• G0557: Level 2, for persons with two or more chronic conditions.
• G0558: Level 3, for persons with two or more chronic conditions and status as a Qualified Medicare Beneficiary.

In a fact sheet issued on November 1, CMS said it had received many requests to increase the valuation for the codes, and will be doing so for G0556.

“Beginning January 1, 2025, physicians and non-physician practitioners (NPPs) who use an advanced primary care model of care delivery as described by the service elements of the APCM codes could bill for APCM services when they are the continuing focal point for all needed health care services and responsible for all the patient's primary care services,” the agency reported. “This new finalized coding and payment better recognizes and describes advanced primary care services, encourages primary care practice transformation, helps ensure that patients have access to high quality primary care services, and simplifies billing and documentation requirements, as compared to existing care management and communication technology-based services codes.”

“The finalized 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,” CMS added. “A practitioner who is participating in a Shared Savings Program ACO, a Realizing Equity, Access, and Community Health ACO (REACH ACO), a Primary Care First practice, or a Making Care Primary practice may satisfy requirements for these codes by virtue of meeting requirements under the Shared Savings Program or Innovation Center model.”

According to Salom, providers seeking reimbursement under one of the three new APCM codes need to satisfy nine requirements:

1. Patient consent (inform the patient of the services, their right to stop, and of the potential cost sharing obligations;
2. Initiating visit (required for new patients and patients not seen by the practice in the last three years);
3. 24/7 access and continuity of care (access to team member for urgent needs at all times and continuity through the use of a dedicated team member);
4. Comprehensive care management (systematic needs assessment, system-based approaches to ensure preventative services are provided, and medication reconciliation, and oversight of patient self-management of medications);
5. Patient-centered comprehensive care plan (the plan should be timely available to those involved with a patient’s care, routinely updated, and provided to the patient and/or caregiver);
6. Management of care transitions (ensuring timely exchange of electronic health information and patient follow-up after emergency room visits and hospital discharges);
7. Practitioner, home-, and community-based care coordination (coordinated referral management with specialists and other health care organizations through developing processes and procedures in the form of collaborative care agreements and electronic consultations);
8. Enhanced communication opportunities (for patients and caregivers to communicate with team members through additional asynchronous methods);
9. Patient population-level management (manage preventative and chronic care for the practice’s patient population and develop and implement strategies to improve outcomes); and
10. Performance measurement (quality, cost of care, and meaningful use of certified electronic health records technology).

“While these new codes come with a number of administrative requirements, the APCM codes provide additional opportunities for practitioners to collect reimbursement for care management services, some of which they may already performing,” Shalom concluded in her post. “HHS has long noted that effective primary care services and relationships are critical to improve health equity and access to care and as early as 2014, CMS recognized care management as a key component of primary care. As such, CMS’s goal in offering these codes is that it will allow practices to enhance or expand their care management services, which in turn will improve population-level mortality and reduce disparities.”