Why CMS’ Proposed New Advanced Primary Care Management Codes are a Big Deal: A Real Movement Forward for Whole-Person Health

Each July, CMS releases a proposed Physician Fee Schedule (PFS) that previews proposed changes to physician payment and other Medicare B services for the upcoming year.  Last year, for example, CMS introduced the Community Health Integration and social determinants of health (SDoH) Risk Assessment codes and previewed them in the 2024 proposed rule.  We are hopeful about the positive impact these changes can foster in our health system, promoting positive health outcomes and advancing whole-person health while simultaneously reducing barriers for service providers. 

For Civitas members, one of the most interesting aspects of the 2025 PFS proposed rule is CMS’ introduction of three advanced primary care management (APCM) codes, which represent a first-of-its-kind attempt to “bundle” several different billable care coordination activities into single G-codes for use by Medicare primary care providers at large. The three proposed APCM codes vary by patient complexity and pay practices for advanced care management on a monthly basis, instead of paying piecemeal on a fee-for-service basis. This is a big move forward in providing practices with reliable revenue to meet the care coordination needs of their patients.  

When Medicare introduces new codes, commercial plans, and Medicaid plans, other payers take note and often introduce them as billable codes, making it possible for practices to apply them across the range of payers they may work with.  

Whether your organization interacts with primary care practices; helps to engage community resources to address social drivers of health; promotes the uses of patient-reported outcome tools; provides data; facilitates gaps in care reporting; or serves people with health and social needs, it helps to have strong primary care partners. Let’s look at the requirements for the proposed new APCM codes: 

• Patient Consent: Inform the patient about the service, obtain consent, and document it in the medical record. 
• Initiating Visit: Engage new patients or those not seen within three years. 
• 24/7 Access: Provide patients with urgent care access to the care team/practitioner at all times. 
• Continuity of Care: Ensure continuity with a designated team member for successive routine appointments. 
• Alternative Care Delivery: Offer care through methods beyond traditional office visits, such as home visits and extended hours. 
• Comprehensive Care Management:
  • Conduct systematic needs assessments. 
  • Ensure receipt of preventive services. 
  • Manage medication reconciliation and oversight of self-management. 

• Electronic Care Plan: Develop and maintain a comprehensive care plan accessible to the care team and patient. 
• Care Transitions Coordination: Facilitate transitions between health care settings and providers, ensuring timely follow-up communication. 
• Ongoing Communication: Coordinate with various service providers and document communications about the patient’s needs and preferences. 
• Enhanced Communication Methods: Enable communication through secure messaging, email, patient portals, and other digital means. 
• Population Data Analysis: Identify care gaps and offer additional interventions. 
• Risk Stratification: Use data to identify and target services to high-risk patients. 
• Performance Measurement: Assess quality of care, total cost of care, and use of Certified EHR Technology (CEHRT). 

Practices need strong, inter-connected data systems to make this happen, and the APCM codes: 

• Require the use of certified electronic health record (EHR) technology (CEHRT) and remote access to the care plan, a helpful step to ease the path to interoperability.  In the proposed rule, CMS notes that CEHRT is, “fundamental to providing the APCM service elements of 24/7 Access to Care, Continuity of Care, and Management of Care Transitions under an advanced primary care delivery model.” By requiring CEHRT, CMS is encouraging practices to electronically report clinical quality, support data exchange with other providers and health systems, and connect to their regional health information exchange (HIE).  
• Provide practices with resources to support patient care optimization and prevent things from slipping through the cracks in transitions of care from an emergency department (ED) or hospital to make sure that patient needs are met. This includes medications being reconciled and following up with patients —either virtually or in-person—in the prescribed timeframes. You can’t do this without information and data exchange about patients seen in an ED or admitted to/discharged from a hospital (for example, via HIE, hospital portal, hospital-generated report, EHR, or additional health IT system); and
• Put practices on track to Medicare Value Pathway reporting and electronic clinical quality measures (eCQMs). 

What could these new codes mean for population health? Looking at states like Michigan that have had experience with CMMI multi-payer models, including APCM-like payments (e.g., multi-payer advanced primary care practice (MAPCP) and Primary Care First (PCF)), might give us a glimpse. Until now, to receive this kind of monthly advanced primary care management funding for their Medicare patients, a primary care practice had to be fortunate enough to qualify for a spot in a Center for Medicare and Medicaid Innovation (CMMI) advanced primary care innovation model with enough other participating payers to cover most of the patients in their panel. When the innovation model ceased, so did the Medicare per member per month (PMPM) funding for advanced primary care management. Even if the commercial payers were able to continue funding, the loss of Medicare and Medicaid funding was often so significant that it was a non-starter for many. It’s margin versus mission, again. The introduction of APCM codes will be a game-changer for these practices.  

Introducing APCM codes, however, is not a silver bullet. There are some aspects of the proposed APCM rule that are less than ideal (the payment rate, the potential for the 10% of Traditional Medicare beneficiaries who do not have Medigap to face the statutory 20% cost share, etc.). CMS would probably have addressed these if it had the authority to do so.  

Let’s not let the perfect be the enemy of the good. There is much that CMS has enabled in the new APCM codes that can unveil a new age of true care integration and coordination.  

In the proposed 2025 PFS rule, CMS has included an extensive RFI section focused on the new APCM code set and future value-based reimbursement models more broadly. Civitas Networks for Health, a national nonprofit collaborative representing over 170 member organizations that are advancing health data exchange and health improvement throughout the U.S. has the ability to bring forward critical perspectives from implementers using data-led multi-stakeholder approaches to both payment and deliver reform. Civitas will speak to the challenges and opportunities created for many of its members’ public comments on the proposed rule, as well as in ongoing communications with regulatory bodies and policymakers to ensure that they understand our perspectives. Civitas will also continue to highlight the technical and operational aspects of value-based care approaches and share best practices among members through its workgroups, collaborative sessions and other forums, such as the Government Relations and Advocacy Council (GRAC).

Our field is ready to move forward with these opportunities CMS is offering to provide better care and promote better health outcomes. We look forward to the next steps and working with fellow Civitas members to implement these critical changes!