Patient consent
Obtained once at enrollment, written or verbal, and documented. The patient must be told that only one practitioner may furnish and bill the service in a given month, and that they may stop at any time.
Insights
What are the 13 APCM service elements?
Advanced primary care management is not paid for minutes. It is paid for a defined set of capabilities being in place for the patient that month. There are thirteen of them.
The Short Answer
Thirteen capabilities, available rather than performed
A practice reporting G0556, G0557 or G0558 must be capable of delivering all thirteen elements to an enrolled patient. It does not have to perform all thirteen every month. The distinction is the whole design of the code family: the question is whether the capability was there, not how many minutes were recorded against it.
That is the clearest break from chronic care management and principal care management, both of which are reported only once a stated number of minutes has been documented. It is also why the elements are worth reading individually: each one is a standing obligation rather than a task to be completed and ticked off.
Several of them are capabilities a small or rural practice cannot realistically staff alone, which is a separate question from whether the practice is eligible to bill.
The Elements
The thirteen, one at a time
Initiating visit
Required for patients the practitioner has not seen within the prior three years, or who are new to the practitioner. Not required for an established patient seen recently.
24/7 access to care
The patient must be able to reach the care team at any hour for urgent needs, and must be told how. This is the element most practices cannot staff on their own.
Continuity of care
A designated member of the care team the patient can expect to see, with continuity across the team rather than whoever is free.
Comprehensive care management
Systematic needs assessment, preventive services, medication reconciliation, and oversight of the patient's self-management.
An electronic care plan
Created, revised and maintained, available to anyone on the care team, and provided to the patient.
Management of care transitions
Covering discharges and emergency visits, including timely exchange of clinical information and follow-up after the event.
Coordination with community-based services
Referral to and coordination with home and community-based social services where the patient needs them, documented in the care plan.
Ongoing patient communication
The patient and caregiver can contact the practice during business hours about routine matters and expect a response.
Enhanced communication
Beyond telephone: patient portal, secure messaging, and other asynchronous channels appropriate to the patient.
Population-level data analysis
The practice can look across its panel rather than one chart at a time, and can show it.
Risk stratification
The panel is stratified so that the patients who need attention are identifiable before they deteriorate.
Performance measurement
The practice reports on quality and cost, through MIPS, a MIPS Value Pathway, or an equivalent arrangement.
What It Replaces
The bundle is a replacement, not an addition
Advanced primary care management incorporates elements of chronic care management, principal care management and transitional care management. Those are not separately reported for the same patient in the same period.
This is the most consequential fact for a practice already running care management. Moving a patient onto the bundle does not add revenue on top of what that patient already generates; it substitutes one payment for the others. Whether that is favorable depends on the panel rather than on the code descriptors, and that is an analysis of a practice's own data rather than a general rule.
A panel where documented time reliably clears the chronic care management thresholds behaves differently under a bundle than one where it does not. Practices that cannot consistently capture and document that time each month are usually the ones for whom the bundle is better, which is the opposite of how it is often sold.
Common Questions
Related questions
Does a practice have to deliver all thirteen elements every month?
No. The practice must be capable of delivering all thirteen and must furnish them as clinically appropriate for the patient. The monthly payment is for the capability being in place, not for a checklist being completed. That is why there is no time threshold attached to the codes.
Is there a time requirement for advanced primary care management?
No, and it is the clearest break from every other care management code. Chronic care management, principal care management and transitional care management are each reported once a stated number of minutes has been documented. These are not. The payment is stratified by patient complexity instead, across three levels.
Which element do practices most often fail on?
Round-the-clock access. A practice can build a care plan, stratify a panel and document a transition with the staff it already has. Guaranteeing that a patient reaching out at nine on a Saturday evening speaks to a clinician who can act is a staffing problem rather than a clinical one, and it is the element most often supplied by a partner rather than built in-house.
Can clinical staff deliver these elements, or only the practitioner?
Clinical staff may furnish the service elements incident to the billing practitioner under general supervision, which does not require the practitioner to be physically present. Those staff may be employed by the practice or may be external to it and under contract. That is the provision that makes an outsourced model workable without adding payroll.
What separates the three levels?
Chronic condition count and qualified Medicare beneficiary status. G0556 covers patients with one or fewer chronic conditions, G0557 covers patients with two or more, and G0558 covers patients with two or more who are also qualified Medicare beneficiaries. The service elements are the same at every level.
Service elements described here reflect CMS guidance current as of CY2026, drawn from the CMS Physician Fee Schedule final rule and the HCPCS code set for G0556, G0557 and G0558. CMS revises requirements and code definitions annually. This is a description of the service, not billing advice for a specific claim, and it carries no payment rates.
Talk it through with someone who runs these programs
Praventa operates care management programs with its own clinical team and licenses the same platform to practices running them in-house. Describe your situation and we will tell you which model fits.