New CMS Care Management Billing Codes Seek to Reduce Administrative Burden and Promote Whole Person, Patient-Centered Care

Recently, the CMS Innovation Center shared the future strategy to "Make America Health Again". The new three pronged approach includes a focus on evidence-based prevention and management of chronic disease, transitioning from a healthcare delivery system that focuses on sick care to a system focused on prevention, wellness and chronic disease management. 

One intervention to aid in helping individuals better manage their chronic condition(s) is the use of care management. Most health systems participating in Alternative Payment Models, including Accountable Care Organizations (ACOs), have ambulatory care managers who work with patients to complete an assessment, provide education, assist with developing self-management goals, and help navigate the healthcare continuum. The ongoing challenge for many health systems and ACOs, however, is covering the labor cost and measuring the downstream return on investment. 

For over a decade, CMS has made multiple attempts to provide reimbursement for care management services in primary care using principal care management (PCM), chronic care management (CCM), and transitional care management (TCM) codes. The implementation of these codes has been limited due to several implementation barriers such as patient consent due to cost sharing, provider engagement, and meeting specific billing and documentation requirements.

As part of the Calendar Year 2025 Physician Fee Schedule (CY 2025 PFS), CMS made available Advanced Primary Care Management (APCM) Services G-Codes to provide fee-for-service reimbursement for care management intervention. The APCM services codes combine elements of PCM, CCM, and TCM billing codes. APCM codes remove time-based requirements, therefore seek to reduce the administrative burden on providers, while promoting whole-person, patient-centered care.Recall, as part of the Calendar Year 2024 Physician Fee Schedule, CMS also made available additional billing codes for care management services, including Community Health Integration (CHI) Services and Principal Illness Navigation (PIN) Services. While well intended, the number of codes available to reimburse for care management work is becoming increasingly more complex given each code has unique requirements, workflow implications, and can be difficult to implement from a clinical, operational and compliance perspective.

In fact, CMS provides a list of General Care Management HCPCS Codes and Descriptors in the CY 2025 PFS Final Rule, and there are over 30 different HCPCS codes available to use for purposes of care management. Specifically, for APCM services the G-Codes, national average per beneficiary per month (PBPM) reimbursement, description of the codes, and associated beneficiary criteria are described in the table below. 

In addition to the details outlined in the CY 2025 PFS, CMS provides a summary of requirements regarding the billing and operational elements needed for APCM codes. Not unlike the requirements for TCM, PCM, and CCM, APCM services codes require the following elements:

• Patient consent

• Initiating visit for new patients

• 24/7 access to care

• Comprehensive care management, including assessment, and self-management support

• Care planning

• Care transitions coordination

• Care coordination with providers and home/community-based care

• Enhanced communication methods

• Population management

• Measurement and reporting

Discussion:

Managing Beneficiaries Across Multiple Programs

On a recent Premier Population Health Management Collaborative webinar, one organization with well-established care management programs (PCM, CCM, TCM) discussed how their team evaluated implementing APCM codes. After careful evaluation, they decided not to move forward because managing patients in multiple programs, using different billing codes, introduces additional complexity to meeting requirements and is counterproductive to the overall aim of reducing administrative burden. For many organizations with existing infrastructure to support PCM, CCM, and TCM billing, this is an important implementation consideration, and in most cases would require an overhaul of workflows including EMR documentation, billing processes, staff training and reporting.

APCM codes may be easiest to implement in organizations that do not have existing programs and workflows. Otherwise, it might be worthwhile to consider employing a strategic approach of transitioning from utilizing PCM, CCM and TCM separately, to APCM for all beneficiaries to ensure all requirements are met and reduce administrative complexity. It is also important to note that while a primary care provider may bill for APCM services in a month, other healthcare providers can also bill for PCM, CCM, CHI and PIN services, if deemed medically necessary. 

Cost Sharing Applies

In the finalized physician fee schedule, CMS acknowledged the challenges associated with beneficiary cost sharing. Some comments submitted on the proposed CY 2025 PFS recommended CMS eliminated cost sharing and other comments suggested that APCM services be categorized as preventative services.  CMS has reiterated that most services covered under Medicare Part B carry cost sharing obligations and they do not have the statutory authority to remove or waive cost sharing. They also do not see how APCM services fit into the preventative services category.

While these barriers may continue to limit the uptake of billing for APCM, consider stratifying patient panels and starting with Qualified Medicare Beneficiaries given the cost sharing coverage. Many care management teams also spend time developing training materials and scripting for staff to aid in describing the overall services and benefits to the patient, so the monthly co-pay is more worthwhile. These cost sharing hurdles should not heavily influence the decision to implement these codes, as many organizations have been successful in overcoming these challenges.

Focus on Patient Engagement

Organization who are successful at engaging patients and billing for care management services have utilized a few key tactics to promote patient engagement. Discussing the benefits of program participation and obtaining consent face-to-face can dramatically increase the likelihood a patient will consent. Telephonic outreach can be difficult to foster engagement, particularly for the first point of contact. Typically, when the relationship has been initiated face-to-face, virtual or telephonic outreach becomes increasingly more effective. Robust staff training and scripting, rooted in motivational interviewing techniques, can also be advantageous. Also, tracking and monitoring beneficiaries who decline and/or may become lost-to-follow can help lead to identifying opportunities for improvement.

Provider Alignment and Buy-in is Essential

There are often challenges with providers having adequate time to discuss the rationale and benefits of engaging with a care manager prior to referring for services. One approach to gain provider buy-in includes understanding the overall relative value unit (RVU) impact for identifying and referring patients for APCM services. Once the referral has been made and beneficiaries agree to participate, the billing should occur monthly, assuming all billing requirements are met. In this case, the provider’s effort on the front end yields an RVU return for subsequent months. Keep in mind, the intent of these codes is for a a primary care provider to bill for services for nearly the entire empaneled traditional Medicare population. As part of the process, also consider the overall impact on provider productivity to ensure downstream alignment with compensation models.

It may also be beneficial to design workflows to incorporate prompts at the point of care, including during Annual Wellness Visits, to make referring simple and easy to complete as part of the provider’s daily workflow. In some instances, viewing the referral like a specialist referral or a medication prescription can be a worthwhile approach that is familiar to providers and beneficiaries. Lastly, some organizations provide dashboards on program activity and share insights from beneficiaries to keep program outcomes top of mind. 

 Summary – Five Key Takeaways:

1. Thoughtfully transition legacy PCM, CCM and TCM programs into one APCM program, and/or develop a new APCM program.

2. Start with engaging Qualified Medicare Beneficiaries to mitigate cost sharing hurdles, while carefully testing effective strategies to foster patient buy-in for cost-sharing commitments across all beneficiaries who are eligible.

3. Engage and align with providers on referral pathways by highlighting RVU and revenue impact, as well as impact on aggregate patient outcomes. 

4. Simplify referral pathways by embedding referral processes into practice workflows.

5. Deploy robust staff training and develop reliable scripting for all staff involved.

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About the Author: Joshua Ison, MAS-PHM, is a Director on Premier’s Strategic Collaboratives team and specializes in helping organizations develop and optimize cross-continuum, population health care management models.

Note: The author of this article is a Premier consultant. The views expressed are his own and do not represent the Premier’s positions or opinions.