New APCM codes present opportunity for RPM
In the 2025 Physician Fee Schedule Proposed Rule, CMS has introduced new codes for Advanced Primary Care Management (APCM) which incorporates elements of Chronic Care Management (CCM), Principal Care Management (PCM), and Communications Technology-Based Services (CTBS) into one set of codes with bundled services.
A step towards value-based care
The new Advanced Primary Care Management (APCM) codes do not require caregivers to log time like the existing CCM and PCM codes. CMS is essentially providing a way for primary care practices to adopt a value-based care model in a small way.
Practices can accept a slightly lower, but easier-to-bill, reimbursement for primary care patients by forgoing billing CCM and PCM time-based codes.
There are three levels to the codes. All require a set of 13 service elements, that most practices billing CCM probably already provide, but no billable time is required.
- GPCM1: Any primary care patient with a proposed rate of $10 per patient per month
- GPMC2: Requires 2 or more chronic conditions similar to the CCM codes with no time requirement at the proposed rate of $50 per patient per month/patient
- GPCM3: Similar to Level 2 but higher reimbursement for Qualified Medicare Beneficiary (QMB) at the proposed rate of $110 per patient per month; this reflects the increased resources required to care for patients under the federal poverty level due to social determinant issues and access to care
The 13 service elements include patient consent, an initiating visit, continuity of care, alternative care delivery, overall comprehensive care management, a patient-centered care plan, 24/7 access to care, coordination of care transitions, ongoing communication, enhanced communication opportunities, population data analysis, risk stratification, and performance measurement. These service elements do not have to be provided to every patient every month but simply need to be “available.”
APCM and CCM Codes
If a practice chooses to bill the APCM codes, they cannot bill CCM, PCM, or TCM time codes. They are effectively choosing a value-based alternative to CCM. While the APCM Level 2 code has a lower reimbursement value than the CCM time-based codes, it can be billed for every patient with chronic conditions regardless of time spent. Practices also lose the potential upside of billing multiple CCM time codes but this may be offset by the higher reimbursement for QMB patients and the Level 1 reimbursement for all primary care patients without chronic care conditions.
Practices can look at the rate at which they successfully bill CCM codes and the overlap of billing multiple CCM codes with QMB patients to determine if the value-based care codes will be worthwhile.
Implications for dual-enrolled RPM and CCM patients
One interesting financial implication of the new codes is for patients enrolled in both RPM and CCM. While ACPM can’t be billed in conjunction with CCM codes, it can be billed with RPM or RTM codes.
Currently, CCM and RPM codes are both time-based. Time spent analyzing RPM readings must be attributed to RPM, but time spent providing care to the patient for their overall condition can count toward either RPM or CCM. Practices are not allowed to double count time but often apply time to CCM first since it has a higher reimbursement rate than RPM.
If a patient qualified for dual enrollment, a practice could bill the APCM codes and then apply all time spent providing care into the RPM time codes, rather than splitting between the RPM and CCM codes. In these cases, a practice could substantially increase RPM reimbursement as more time could be attributed to RPM. If a practice can bill extra instances of CPT Code 99458 for incremental blocks of 20 minutes while still collecting the APCM reimbursement, that is likely a win
Opportunities for RPM companies
CMS is specifically asking for comments on how ACPM should work with RPM. As CMS strives to move more and more towards value-based care, RPM could ultimately be absorbed into the ACPM codes. But for now, RPM companies have an opportunity to educate their practices on the additional reimbursement opportunity for dual-enrolled CCM-RPM patients if they choose to use the ACPM codes.
Continua is here to help
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