By Sudeep Bath | October 9, 2025

Hospitals and FQHC teams adopting Advanced Primary Care Management (APCM) programs in 2025

In 2025, the Centers for Medicare & Medicaid Services (CMS) introduced significant updates to support Advanced Primary Care Management (APCM) – a proactive, value-based model of delivering primary care. A strong primary care foundation is key to improving health outcomes and reducing disparities, which is why CMS and HHS have been taking action to strengthen primary care and reward care coordination[1]. The 2025 Medicare Physician Fee Schedule (PFS) final rule reflects a broader strategy for a more equitable, high-quality healthcare system with better access, affordability, and innovation for all Medicare beneficiaries[2]. Below, we break down the latest CMS updates on APCM, related care management programs, new reimbursement structures, and policy changes that hospitals and Federally Qualified Health Centers (FQHCs) need to know.

Table of Contents

New APCM Codes and Policy Changes in 2025

CMS has established new APCM service codes effective January 1, 2025 under the Physician Fee Schedule. These are three monthly HCPCS G-codes (G0556, G0557, G0558) that bundle together several care management and telehealth services into one comprehensive payment[3]. The APCM bundle incorporates elements of Principal Care Management (PCM), Transitional Care Management (TCM), Chronic Care Management (CCM), and communication technology-based services (like virtual check-ins, remote evaluations of patient data, e-visits, and interprofessional consultations)[4][5]. In other words, many care coordination activities that providers previously billed separately are now combined into a single monthly APCM service reflecting the essential elements of advanced primary care.

APCM is designed to simplify billing and reduce administrative burden. Unlike traditional CCM/PCM codes that required documenting a minimum amount of clinical time (e.g. 20 minutes per month for non-complex CCM), the new APCM codes have no time-based threshold for billing[6]. Providers no longer need to track minutes spent on each activity – they can bill the APCM code once per patient per month as long as they fulfill the required service elements. This streamlining helps “simplify…billing and documentation requirements” while ensuring patients receive comprehensive care[7]. CMS explicitly intends this change to reduce the administrative burden on practitioners, freeing up time to focus on patient care rather than paperwork[6].

The three APCM codes are stratified by patient complexity to account for varying needs and resources[8]:

G0556 – APCM, Level 1: For patients with one (or no) chronic condition, under the care of a primary care provider. (This is the base APCM code, often managed by clinical staff under physician supervision.)[9]
G0557 – APCM, Level 2: For patients with two or more chronic conditions expected to last 12+ months and placing the patient at serious risk (e.g. hospitalization or functional decline)[10]. This code reflects higher complexity and pays more than G0556.
G0558 – APCM, Level 3: For patients with two or more chronic conditions who are also Qualified Medicare Beneficiaries (QMB) (low-income Medicare patients dual-eligible for Medicaid)[11]. This highest tier carries the highest monthly reimbursement, acknowledging the greater medical and social complexity in this population[9]. (Notably, QMB patients are exempt from cost-sharing, and CMS created a separate code to ensure providers are fully reimbursed for their care[12][13].)

CMS finalized increased valuation for the APCM codes in the final rule after public comments, including a boost to the Level 1 payment rate[14]. While exact dollar amounts are set by the Medicare fee schedule (e.g. approximately $15 per member per month for G0556, ~$50 for G0557, and ~$110 for G0558 in 2025 under national rates)[15][16], the key point is that higher-need patients warrant higher APCM payments. This risk-tiered payment structure aligns incentives with patient complexity, rewarding providers for managing sicker patients and addressing social risk factors.

Importantly, APCM is optional and additive – practices may choose to bill these new codes if they meet the requirements, or continue using traditional care management codes. Beginning in 2025, physicians or qualified non-physician practitioners (NPs, PAs, CNSs) who serve as the primary care focal point for a patient’s care can bill APCM for that patient[17][18]. Specialists who function as a patient’s main provider (for example, a cardiologist managing a patient’s comprehensive care) may also use APCM if they assume primary care responsibilities[19]. Only one practitioner can bill APCM for a given patient in a month, and the patient must give consent to participate (they can opt out at any time)[20]. If APCM is billed for a month, the patient cannot concurrently be billed for CCM, PCM, or TCM by anyone else in that month[21], to prevent duplicate payments for similar services. In short, APCM consolidates care management billing under the primary provider responsible for that patient.

Billing Requirements and Care Elements under APCM

To bill an APCM code, providers must deliver a comprehensive set of advanced primary care services (during the month) and meet specific requirements outlined by CMS. These requirements form a kind of care delivery framework that emphasizes access, coordination, and planning. Key APCM service elements include[22][23]:

Patient Consent and Exclusivity: Obtain the patient’s written or verbal consent to enroll in APCM services and document it in the medical record[20]. The patient must be informed that only one provider can bill for APCM per month, they have the right to stop anytime, and standard Medicare cost-sharing (copay/coinsurance) applies (except for QMB patients who owe no coinsurance)[24][25]. Consent is required only once upon initiation.
Initiating Visit (if needed): For new patients or those not seen recently, conduct an initiating visit (e.g. an Annual Wellness Visit or evaluation) to establish care before starting APCM[26]. If the billing provider or someone in the practice has seen the patient within the last 3 years (or provided care management within the last year), a new initiation visit is not required[27]. This ensures the provider has an up-to-date assessment and care plan in place.
24/7 Access and Continuity of Care: Provide round-the-clock access for patients or caregivers to get urgent needs addressed by a care team member with real-time access to the medical record[28]. Patients should have continuity in their care – for example, the ability to see the same care team members for routine appointments – and practices should offer alternatives to traditional office visits (such as extended hours or home visits) to improve access[29].
Comprehensive Care Management & Care Planning: Perform systematic assessment of patient needs (both medical and psychosocial), medication reconciliation and management, and ensure preventive care is up to date[30][31]. Develop or update a patient-centered care plan in the electronic health record that outlines the patient’s issues, goals, and interventions[32]. The care plan must be accessible to all providers involved in the patient’s care and a copy should be given to the patient or caregiver[33]. This ongoing care management is at the heart of APCM, targeting chronic conditions and whole-person wellness.
Coordinating Care Transitions: When patients move between settings of care, the APCM provider coordinates transitions to prevent gaps. This includes making timely referrals to specialists or community services, following up after emergency department visits or hospital discharges, and ensuring information flows between providers[34]. CMS specifies, for example, that after a hospital or ER discharge, the practice should reach out to the patient (by phone or electronically) within 7 days to follow up, as clinically appropriate[35]. Efficient care transition management (a hallmark of TCM) helps reduce readmissions and keeps the primary care provider in the loop on all patient care activities.
Integration of Community and Social Support: APCM isn’t limited to medical issues – providers must also coordinate with home- and community-based services as needed[30]. This could involve connecting patients with nutrition programs, transportation, caregiver support, or social services and then documenting the patient’s psychosocial needs and community resources in the care plan. Addressing social determinants of health in this way is part of the “advanced” approach to primary care.
Enhanced Communication (Technology-Based): Leverage digital and remote communication tools to engage patients. The practice should offer asynchronous, non-face-to-face communication methods beyond just phone calls – for example, secure messaging or patient portal emails[36]. They must be capable of conducting remote evaluations of patient-generated data (like reviewing a photo or video a patient sends in) and e-consultations with other professionals[37]. APCM providers also need to support patient-initiated digital communications that require clinical decisions, such as “virtual check-in” calls, online assessments (e-visits), and other telehealth E/M services[38]. By embracing telehealth and communication technology, the care team can manage issues promptly without always requiring an in-person visit.
Population Health Management: Practices should use data analytics to proactively manage their patient panel. This includes analyzing patient population data to identify care gaps (for example, which patients are overdue for screening or are frequent ER users) and risk-stratifying patients based on conditions or claims data to target those most in need of intervention[23]. In short, APCM encourages providers to think at both the individual level and the population level – identifying high-risk patients and intervening before small issues become big health crises.
Performance Measurement and Quality Reporting: APCM services include an element of tracking and reporting outcomes to ensure accountability for quality and cost. CMS allows two ways to fulfill this requirement: (1) report the “Value in Primary Care” MIPS Value Pathway (MVP) – a tailored set of quality measures for primary care clinicians – starting with the 2025 performance period (reported in 2026)[39]; or (2) participate in an alternative value-based model like an Accountable Care Organization (ACO) or a CMS primary care initiative, which comes with its own quality tracking[40]. In fact, CMS notes that providers participating in a Shared Savings Program ACO, the ACO REACH model, Primary Care First, or the new Making Care Primary model will automatically satisfy the APCM performance measurement element by meeting their model’s requirements[41]. This flexibility is meant to integrate APCM with broader value-based care efforts. FQHCs and RHCs, which are not eligible for MIPS, are exempt from the MVP reporting requirement altogether under the APCM policy[42].
Team-Based Care – Use of Auxiliary Personnel: CMS explicitly allows clinical staff and auxiliary personnel to perform APCM services “incident to” the billing provider’s care, under general supervision[43]. This means nurses, medical assistants, care managers, pharmacists, and other staff can handle much of the care coordination work, as long as a physician or NP/PA is overseeing the process. General (as opposed to direct on-site) supervision is permitted, reflecting the reality that care management often happens over the phone or via telehealth without the physician present. By empowering care teams and even enabling partnerships with third-party care management companies, this policy helps practices scale up care management without overwhelming physicians[44]. The billing provider remains responsible for the patient’s care plan and must initiate the service (via the required visit), but the day-to-day outreach and care coordination can be delegated to a trained team.

Overall, these requirements align closely with the standards from patient-centered medical home models and previous CMS innovation projects. They ensure that if a provider is billing for APCM, they are delivering truly “advanced” primary care – accessible, continuous, coordinated, comprehensive, and accountable care. While meeting all these criteria requires robust practice infrastructure, CMS’s goal is to incentivize providers to transform their practices in exchange for predictable monthly payments. Indeed, CMS drew on lessons learned from prior primary care initiatives (like Comprehensive Primary Care Plus and Primary Care First) to define the APCM standards[45]. Practices that invest in care management capabilities can see not only improved patient outcomes (fewer hospitalizations, higher satisfaction) but also new revenue streams through these monthly payments and potential bonus savings in ACO models[46][47].

Benefits of APCM for Providers: In addition to better patient outcomes, the APCM program offers concrete benefits for providers in 2025:

Streamlined Billing: Instead of juggling multiple care management CPT codes (CCM, PCM, TCM, etc.) and tracking time for each, providers can bill a single code per month for all-encompassing care[6]. This simplifies claims and reduces the risk of documentation errors. It also reduces repetitive tasks – for example, one comprehensive note can cover the APCM requirements, rather than separate notes for each 20-minute block of CCM.
More Predictable Payment: The monthly APCM fee (often called a per-member-per-month payment) provides a steady revenue for managing a patient, whether or not that patient comes in for a visit. This offers stability, helping practices invest in care management staff and tools. It’s a step toward hybrid payment models (blending fee-for-service with population-based payment), which CMS sees as crucial for supporting longitudinal primary care[48]. In fact, CMS describes APCM as “a step towards paying for primary care with hybrid payments…by paying for care in larger units of service” and promoting accountable care relationships[49].
Alignment with Value-Based Incentives: By participating in APCM, providers position themselves for success in broader value-based care programs. The care processes required (like 24/7 access, follow-ups, care planning) closely overlap with quality measures and utilization metrics that ACOs and MIPS track. CMS is essentially aligning APCM with its value-based purchasing goals – for example, requiring the MIPS Value in Primary Care reporting or ACO participation[40]. Providers who adopt APCM will likely perform better in quality programs and avoid penalties, all while earning the APCM payments. CMS also notes that these codes “help drive accountable care” by supporting the sustained provider-patient relationships needed for shared savings models[49].
Focus on Complex Patients and Prevention: The stratified payment levels mean providers are rewarded for enrolling complex, high-need patients – those who most benefit from intensive care management. There is also no longer an eligibility restriction of “2+ chronic conditions only” as with traditional CCM. Every Medicare patient, even those with a single chronic condition or at risk, can be engaged in APCM[50]. This expanded eligibility allows practices to deliver preventive, proactive care to a broader group, catching issues early. For hospitals and FQHCs, this can translate into reduced emergency visits and admissions (a key outcome for value-based contracts) by managing patients more tightly in the outpatient setting[47].

In summary, APCM in 2025 represents a major shift in Medicare’s approach to primary care reimbursement – one that bundles chronic care, transitional care, and virtual care into a unified package. It aligns payment with the kind of continuous, coordinated care that leads to better outcomes. Hospitals, health systems, and FQHCs that embrace APCM will find themselves closely aligned with CMS’s strategic priorities of improved quality and cost control in primary care.

Chronic Care Management (CCM) and Principal Care Management (PCM) Updates

Chronic Care Management (CCM) and Principal Care Management (PCM) are foundational Medicare care management programs that paved the way for APCM. CCM, introduced in 2015, provides reimbursement for managing patients with two or more chronic conditions through non-face-to-face care coordination (phone check-ups, medication management, etc.)[51]. PCM, introduced more recently (2020), is akin to CCM but for patients with a single serious chronic condition – it enables specialists or primary providers to bill for focused care management of one complex condition (for example, a cardiologist managing heart failure).

Key CCM/PCM facts: Under traditional CPT coding, CCM required at least 20 minutes of clinical staff time per month on care coordination (billed with CPT 99490 for basic CCM). Additional time or higher complexity could be billed with add-on codes (e.g. 99439 for each extra 20 minutes, or complex CCM codes 99487/99489 for 60+ minutes of moderate-to-high complexity care). PCM codes (CPT 99424, 99425, etc.) similarly had time requirements (30 minutes by physician/NP or clinical staff). These services have been proven to improve patient outcomes by ensuring regular touch-points between visits – for instance, medication adjustments or specialist referrals coordinated by the care manager. However, the time-tracking and paperwork burden made some providers hesitant to fully adopt CCM/PCM in the past.

With the advent of APCM in 2025, CMS is offering an alternative to the time-based CCM/PCM billing. The APCM codes essentially combine CCM and PCM services (along with TCM and others) into one bundle[52]. For providers who meet the APCM requirements, this means they no longer need to count minutes for separate care management codes – the single APCM code can replace multiple CCM/PCM codes in a given month. For example, rather than billing 99490 (CCM) plus 99439 (add-on) for a patient with diabetes and COPD, a practice could bill G0557 (APCM Level 2) once, as long as they provided the comprehensive scope of services. This reduces duplicative billing and ensures the provider is focusing on holistic care, not just one condition at a time.

That said, the traditional CCM and PCM codes are still active and available in 2025. Providers not ready for APCM, or who only meet some of the requirements, can continue to bill CCM (for patients with 2+ chronic conditions) or PCM (for qualifying single-condition patients) as before. In fact, CMS expects some providers will transition gradually. A patient cannot be enrolled in both APCM and CCM/PCM concurrently – it’s one or the other per month[21]. Practices will need to choose the approach that fits their care processes. For instance, a specialty clinic that only wants to manage one condition might stick with PCM codes, whereas a primary care clinic capable of full care coordination might opt into APCM for a more inclusive payment.

Important 2025 update for FQHCs/RHCs: Historically, FQHCs and Rural Health Clinics could not bill the regular CCM CPT codes directly. Instead, Medicare created a special code G0511 (General Care Management) that FQHCs/RHCs could use to bill for CCM or similar care management services on their cost-based system. G0511 paid a set amount (around $74 in 2024) per 20-minute care management service and could be billed up to twice per month per patient[53][54]. In effect, G0511 bundled CCM, PCM, and even BHI (behavioral health integration) into one all-purpose code for those rural providers[53].

For 2025, CMS is eliminating code G0511 and moving FQHCs/RHCs onto the standard coding for care management. After a transition period (through June 30, 2025), FQHCs and RHCs will report the individual CPT CCM/PCM codes instead of the single G0511[54][55]. They will also be allowed to bill the add-on codes (e.g. CCM’s 99439) for additional time, which was not possible with G0511[56]. Payment for these services at FQHCs/RHCs will be made in addition to the usual per-visit clinic rate (PPS or AIR), at the national Physician Fee Schedule rate for each code[57]. This is a significant change: it aligns FQHC/RHC billing with other provider types, increases transparency about which specific services are delivered, and potentially improves payment accuracy. However, it may reduce revenue per service for some clinics – G0511’s rate was higher than the standard CCM rate, so billing 99490 will net less (about a 14% reduction per service by one estimate)[58]. CMS delayed full implementation to mid-2025 to give these clinics time to adjust systems and workflows[59].

Practical takeaway: FQHCs and RHCs should prepare to update their billing systems and train staff on the new coding procedures for care management by July 2025. They’ll need to track and bill each program (CCM, PCM, BHI, etc.) separately. Alternatively, as CMS points out, FQHCs/RHCs “who don’t want to bill each care management service separately can consider offering the new APCM program instead.”[60] If an FQHC can meet the APCM requirements, it might opt to enroll patients in APCM and bill G0556–G0558 monthly, simplifying billing to one code again (but now with more responsibilities attached). Notably, CMS has extended APCM to FQHC/RHC settings as well – those clinics can bill the APCM G-codes and get paid the same as any other practice (paid on top of the clinic’s normal visit rate)[57]. And because FQHCs are exempt from MIPS, they are not forced to do the quality reporting MVP – though they are still expected to fulfill the care activities of APCM[42].

In summary, CCM and PCM remain crucial components of chronic care, but 2025 brings a shift in how they’re packaged and reimbursed. CMS is steering providers toward more comprehensive management via APCM, while also making the legacy programs more accessible in rural settings through coding changes. Hospitals and clinics should review these changes carefully: you may need to adapt your billing (especially if you’re an FQHC/RHC), and weigh the financial and operational pros/cons of sticking with traditional CCM/PCM versus adopting the new APCM bundle.

Transitional Care Management (TCM)

Transitional Care Management (TCM) services are another pillar of advanced primary care, aimed at safely guiding patients through the vulnerable period after a hospital or facility discharge. TCM has been part of Medicare since 2013, using CPT 99495 and 99496 to reimburse providers for managing a patient’s transition for 30 days post-discharge (including a timely follow-up visit and coordination of services). TCM rewards practices for preventing readmissions and complications by actively following up when a patient comes home from the hospital.

In the context of 2025 updates, TCM is explicitly included in the APCM framework. CMS lists Transitional Care Management as one of the care management services bundled into APCM monthly services[61]. Practically, this means if you are providing TCM for a patient and you are enrolled in APCM, you would likely just bill the APCM code for that month rather than separate TCM codes. The required follow-up visit and outreach after discharge would count toward your APCM service elements (e.g. “care transitions coordination” and “follow-up within 7 days of discharge” are built into APCM requirements[62]).

If a provider is not using APCM, TCM can still be billed normally using 99495/99496 for eligible discharges. There were no major changes to TCM coding in the 2025 PFS rule – the reimbursement and requirements remain as before (99495 for moderate complexity post-discharge care with a face-to-face visit within 14 days; 99496 for high complexity with a visit within 7 days). What’s changing is how TCM fits into the bigger picture: CMS is encouraging its integration with continuous care management. Providers who adopt APCM will inherently perform TCM tasks as part of that monthly care cycle, potentially improving outcomes. In fact, reducing readmissions and emergency visits is a key goal of the APCM model and other CMS initiatives[47]. Hospitals in particular should note: effective TCM (whether via traditional billing or APCM) directly helps avoid the costly revolving door of readmissions, which also aligns with Medicare’s Hospital Readmission Reduction Program incentives.

One subtle benefit of the APCM approach is that it can eliminate the billing conflict between TCM and CCM. Previously, Medicare did not allow certain combinations of monthly care management codes in the same service period – for example, you typically couldn’t bill CCM in the same month as TCM, since TCM’s 30-day period overlaps with a month of CCM. Under APCM’s single bundle, you don’t have to choose; the work of TCM simply becomes part of the overall advanced primary care service for that month. This is administratively simpler and financially advantageous (you’re compensated via the APCM code, and not missing out on either TCM or CCM payment).

In summary, Transitional Care Management remains a vital service in 2025, and CMS views it as part of the continuum of advanced primary care. Providers should continue to ensure all discharged patients get timely follow-up calls and visits as per TCM guidelines – and they can now fold those activities into the APCM program if participating. By doing so, practices contribute to the value-based goals of fewer readmissions and smoother care transitions, which benefit both patients and healthcare systems.

Remote Patient Monitoring (RPM) and Digital Health Services

Remote Patient Monitoring (RPM) has emerged as a key component of managing chronic conditions by leveraging technology to track patient health data between visits. Medicare began reimbursing RPM services in recent years (CPT codes 99453, 99454, 99457, 99458, etc.), allowing providers to bill for setting up devices, collecting patient physiologic data (like blood pressure, glucose, weight readings), and managing patients based on those remote readings. RPM enables a more continuous, preventive approach to care – issues can be identified and addressed in real time, rather than waiting for the next office visit.

In 2025, CMS continues to support RPM as a distinct billable service, and while RPM isn’t explicitly packaged into the APCM codes, it is highly complementary to the APCM model. APCM encourages use of technology and patient monitoring as part of enhanced care. For example, one of the communication technology-based services included in APCM is “remote evaluation of recorded patient information”[63], which could encompass reviewing data from a remote monitoring device or app. Additionally, APCM requires practices to offer digital communications and follow-ups – an RPM program naturally dovetails with that by feeding the care team regular data on the patient’s condition.

Providers can continue to bill RPM codes separately alongside APCM if they are furnishing those services. CMS has not indicated any prohibition on billing RPM (e.g. 99457) during the same month as APCM – they cover different aspects (RPM covers time spent managing device data, which isn’t explicitly counted in APCM’s bundle). However, providers should ensure no “double counting” of work: for instance, if RPM device monitoring is a routine part of your care process, the patient interactions resulting from it might be considered part of care management. Clarifying guidance may emerge, but as of the PFS final rule, RPM remains an independent program that advanced practices can utilize to enhance outcomes. In short, APCM and RPM can work hand-in-hand: APCM pays for the care management infrastructure (staff, care plans, coordination), while RPM pays for the technology-driven monitoring that feeds into that care.

For FQHCs/RHCs, billing of RPM was historically tricky under the all-inclusive rate system. CMS had allowed some use of G0511 for certain remote monitoring or digital check-in services[53], but with the 2025 shift to general codes, it’s expected that FQHCs/RHCs will be able to bill RPM CPT codes directly similar to other providers. The final rule’s language about reporting “individual CPT and HCPCS codes” for care coordination likely extends to remote monitoring services as well[64]. This means a rural clinic could potentially bill 99454 (device supply) and 99457 (management) for a patient, and receive additional payment beyond the clinic visit rate[57]. They will need to follow Medicare’s requirements (e.g. 16 days of readings in a month for 99454) as usual.

Continued Telehealth Flexibilities: Another 2025 policy note is that CMS is maintaining certain telehealth and supervision flexibilities which facilitate remote care. For instance, CMS will allow direct supervision via real-time audio-video through 2025, meaning supervising physicians can oversee clinical staff remotely for services incident-to (this supports things like centralized RPM nurses under physician supervision from another site)[65][66]. Also, RHCs and FQHCs can continue to provide services via telehealth (using code G2025 for distant site telehealth) through the end of 2024, with many flexibilities extended through 2025 by CMS or pending legislation[67]. And the requirement for an in-person visit within 6 months of a tele-mental health service has been delayed until 2026[68] – making it easier to deliver behavioral health services remotely (important for integrating mental health, as discussed below).

All these telehealth measures align with CMS’s goal to “preserve…expand access to telehealth services where appropriate”[69]. For advanced primary care, this means providers can confidently use virtual visits, telemonitoring, and digital communication as part of their care models in 2025 without fearing loss of Medicare coverage for those activities. RPM, specifically, remains a Medicare-covered service with increasing importance in managing chronic disease – so much so that many APCM-oriented practices will likely use RPM data to achieve the proactive, preventive care outcomes that CMS is targeting.

To summarize, Remote Patient Monitoring is a vital tool in the advanced primary care toolbox for 2025. While it carries its own billing codes and requirements, it complements the APCM bundle and other care management services. Hospitals and clinics implementing APCM should consider augmenting their programs with RPM for patients who would benefit (for example, CHF patients with daily weight monitoring or diabetics with continuous glucose monitors). By catching warning signs early via RPM and intervening through APCM care coordination, providers can significantly improve patient stability and reduce acute care utilization, which is exactly the kind of high-value care CMS wants to incentivize.

Behavioral Health Integration (BHI) in Primary Care

CMS’s push toward advanced primary care also emphasizes Behavioral Health Integration (BHI) – recognizing that managing mental and behavioral health conditions is integral to overall health, especially for patients with chronic illness. BHI in Medicare typically refers to two sets of codes: – The General BHI code (CPT 99484), which covers monthly care management for patients with behavioral health conditions, typically provided by the primary care team with a behavioral health manager consulting. – The Psychiatric Collaborative Care Model (CoCM) codes (CPT 99492, 99493, 99494, and HCPCS G0512 for FQHC/RHC), which reimburse a more structured team-based model where a primary care physician, a behavioral health care manager, and a psychiatric consultant work together to manage a patient’s mental health needs.

These BHI programs are a crucial piece of advanced primary care, as many patients have co-occurring physical and mental health conditions. Effective integration can improve outcomes (for example, treating depression can help a diabetic patient better manage their diabetes) and reduce total costs.

CMS has continued to promote BHI in 2025 through both coding policy and broader behavioral health strategy. Some relevant updates and points:

As mentioned, FQHCs and RHCs will start billing 99484 and related BHI codes directly instead of using G0511, after June 2025[70]. This means these clinics can report exactly what type of behavioral health management they are providing. For the Collaborative Care Model, FQHCs have used HCPCS G0512 (which pays for CoCM activities); it’s likely that CMS will eventually align this as well, potentially allowing FQHCs to use the standard CoCM CPT codes. (The final rule did not explicitly mention G0512, but the expectation is consistency in moving away from generic G-codes.)
APCM’s scope inherently includes behavioral health needs. While APCM codes are not specific to mental health, the comprehensive care plan and care coordination elements require addressing all of a patient’s health issues, including depression, anxiety, or other behavioral conditions. The model requires coordination with community resources and specialists – which can include mental health providers – and ensures 24/7 access, which can be critical for patients in crisis. In fact, CMS’s Behavioral Health Strategy emphasizes integrating behavioral healthcare into routine care settings[71], and APCM provides an infrastructure (e.g. monthly follow-ups, population health tracking) to do just that.
New Behavioral Health services in 2025: CMS finalized new codes to expand access to certain mental health interventions. Notably, Medicare will pay for Safety Planning services (for suicide prevention) in 2025 – a new code that can be billed in 20-minute increments for specialized intervention when patients are in crisis[72]. Additionally, CMS is introducing coverage for digital mental health treatment tools (FDA-cleared digital therapeutics for conditions like substance use or anxiety) which can be provided as part of behavioral treatment plans[73]. They’re also allowing mental health specialists (like psychologists and social workers) to bill new interprofessional consultation codes (to consult with primary care providers) to better integrate care[74]. All of these efforts fit the theme of reducing barriers to behavioral healthcare and encouraging collaboration between primary care and mental health professionals.
Tele-mental health access remains a priority: As noted earlier, CMS delayed the in-person visit requirement for telehealth mental services, ensuring patients can continue to get therapy or psych consults via telehealth without jumping through extra hoops until at least 2026[68]. Also, REACH ACOs and other models are offering enhanced benefits that often include expanded tele-behavioral health access[75]. For primary care, this means it’s easier to bring behavioral health services into your practice workflow (e.g. via tele-consults with a psychiatrist, or having a therapist do video visits with patients in the clinic).

For hospitals and clinics, what this boils down to is: integrating behavioral health is no longer optional – it’s becoming a standard expectation in advanced primary care models. Medicare provides reimbursement to support it (through BHI/CoCM codes and now APCM payments that implicitly cover coordination with behavioral health). The incentives are aligned to encourage treatment of the “whole person.” Providers should leverage these codes and policies to incorporate screening for depression/anxiety, have care managers follow up on behavioral issues, and collaborate with mental health specialists as needed. Doing so will improve patient well-being and is likely to improve performance metrics (since behavioral health conditions, if unmanaged, drive up costs and worsen outcomes for other diseases).

In 2025, CMS’s messaging is clear: behavioral health integration is a core component of primary care quality. Whether through CoCM, general BHI, or the broad APCM requirements, primary care teams are encouraged and incentivized to address behavioral conditions with the same priority as physical conditions. This reflects the healthcare system’s shift toward recognizing mental health as essential to overall health – a culture change strongly backed by Medicare’s payment policies.

ACO REACH and Primary Care First: Value-Based Models Supporting APCM

Alongside fee-for-service enhancements like APCM, CMS is aggressively promoting value-based care models that reward providers for quality and cost outcomes at the population level. Two key initiatives related to advanced primary care are ACO REACH and Primary Care First, which continue in 2025 and align with the goals of APCM.

ACO REACH (Realizing Equity, Access, and Community Health ACO Model)

ACO REACH is an Innovation Center model (running 2023–2026) that represents the next generation of Accountable Care Organizations with a focus on health equity and increased provider risk-sharing. It was redesigned from the Direct Contracting model and launched its first performance year in 2023[76]. In the ACO REACH model, groups of providers – often led by primary care practices – come together as an ACO to manage a population of Medicare patients with the goals of coordinating care, improving quality, and reducing costs[77]. What sets REACH apart are policies to ensure provider governance, stricter oversight to protect patients, and requirements to address underserved communities’ needs.

For 2025, ACO REACH has robust participation nationwide. In Performance Year 2025, 103 ACOs are participating in ACO REACH, covering beneficiaries across all 50 states, D.C., and Puerto Rico[78]. CMS is not accepting new applications (the model is in progress), but those ACOs currently in REACH are implementing advanced primary care strategies at scale.

Key features of ACO REACH that tie into APCM and primary care improvement:

Capitated Payments and Risk Options: ACO REACH offers two risk tracks – a “Professional” option with 50% shared savings/losses and a “Global” option with 100% full risk. Both tracks include capitation payments for primary care services (either Primary Care Capitation or Total Care Capitation) where providers receive a risk-adjusted per-beneficiary per month payment upfront[79]. This model of payment allows participating practices to invest in care management infrastructure (similar to how APCM provides per-month payments) and gives flexibility to deliver care in innovative ways (like telehealth, home visits, etc.) without worrying about individual FFS billing for those services. Essentially, REACH ACOs are already operating under a hybrid payment structure that aligns financial incentives with keeping patients healthy.
Care Coordination and Enhanced Benefits: Patients aligned to REACH ACOs benefit from more coordinated care. Providers in the ACO share data and communicate across settings, reducing duplication and conflicting treatments[77]. Many REACH ACOs offer enhanced benefits to patients such as telehealth waivers, home care after hospitalization, and even help with co-pays for certain services[75]. These flexibilities encourage primary care teams to address needs holistically (for example, offering a home visit or remote monitoring if it can prevent a hospitalization).
Focus on Equity: A major thrust of ACO REACH is to address health equity. There are requirements for participant ACOs to develop an Equity Plan and there are adjustments in the payment benchmark to incentivize enrollment of underserved beneficiaries. Primary care practices in these ACOs might, for instance, deploy community health workers or offer transportation for appointments, aligning with the community-oriented elements that APCM also emphasizes (like connecting patients with social services).

How does ACO REACH relate to APCM? CMS views them as complementary. Participation in an ACO (whether REACH or the permanent Medicare Shared Savings Program) can satisfy the performance reporting requirement of APCM codes[80], meaning an ACO participant is presumed to be engaging in quality measurement and improvement. Moreover, practices in REACH ACOs are likely already doing many of the care activities that APCM requires (24/7 access, care coordination, etc.), as those are best practices for succeeding under shared savings. In fact, the APCM code description explicitly notes that a provider in a Shared Savings ACO or REACH ACO may meet the APCM requirements “by virtue of” meeting their ACO’s requirements[80]. Therefore, providers in REACH ACOs can potentially bill APCM codes as an additional revenue source on top of their capitated payments, if they choose, without duplicative effort – the care processes are aligned.

From a strategic standpoint, CMS’s goal is to have all Medicare beneficiaries in an accountable care relationship by 2030, and expanding advanced primary care is a means to that end. ACO REACH is one pathway, and the APCM codes in FFS are another; both are pushing providers towards the same ultimate practice model. Hospitals and health systems in REACH ACOs should ensure their primary care teams know about APCM – it could be a win-win, boosting their fee-for-service revenue for care management while they work towards shared savings.

Primary Care First (PCF) Model

Primary Care First is another CMS Innovation model that specifically targets primary care practices, testing a novel payment structure to promote advanced primary care. Launched in 2021, Primary Care First offers participating practices a combination of population-based payments (a flat monthly fee per patient), reduced fee-for-service payments for visits, and the opportunity for performance-based adjustments to revenue based on quality and utilization outcomes. It essentially gives primary care providers upfront resources and then rewards them for keeping patients healthy and out of the hospital. PCF also required participants to meet certain care delivery criteria (e.g. same-day access, care management for high-need patients, etc.), very much in line with the APCM service elements.

By 2025, Primary Care First is ongoing (though enrollment had been limited to certain regions and is closed to new practices as the model progresses). Like ACO REACH, PCF is aligned with APCM – CMS explicitly listed a Primary Care First practice as an example of where APCM requirements would be inherently met[80]. In other words, if you’re a PCF practice, you are likely already doing comprehensive care management, so you could bill APCM codes for your Medicare patients to get additional compensation for that work. PCF participants have a lot of their Medicare revenue in capitated form, but nothing precludes billing care management codes for things outside the cap. CMS has signaled that involvement in PCF covers the “performance measurement” aspect of APCM (because PCF has its own rigorous quality monitoring).

It’s worth noting that Primary Care First and the new APCM codes share a common lineage: both were informed by the earlier Comprehensive Primary Care Plus (CPC+) demonstration. CPC+ (2017-2021) showed that paying for care management and requiring multi-faceted primary care improvements could reduce ED visits and improve quality[81][82]. The 2025 PFS rule preamble acknowledges using lessons from CPC+ and PCF to design APCM[45]. Essentially, APCM is an attempt to bring those model concepts to the broader Medicare program so practices not in a specific demo can still move towards advanced primary care.

For hospitals and larger systems, Primary Care First might only involve certain clinics, but the general idea is that CMS is experimenting with partial capitation and outcomes-based bonuses in primary care. Even if you’re not in PCF, the APCM codes allow you to start practicing in a similar way (focusing on care between visits, population health, etc.) within traditional Medicare billing. Keep an eye on PCF’s results – if it shows cost savings and quality gains, CMS may expand such approaches. In fact, CMS has announced a new model called Making Care Primary (MCP) set to begin in 2024 in several states, which will build on PCF and could be a future nationwide model. APCM positions providers to be ready for that future, since it requires many of the same capabilities.

Aligning Incentives for Provider Adoption

Both ACO REACH and Primary Care First (as well as the Shared Savings Program ACOs and the upcoming Making Care Primary model) underscore CMS’s commitment to value-based care. The incentives being aligned include:

Financial rewards for outcomes: Shared savings in ACOs or performance bonuses in PCF can be significant if providers can reduce hospital utilization and meet quality targets. This motivates practices to invest in care coordinators, data systems, and team-based care – which are exactly what APCM supports with its payments. Essentially, APCM payments can fund the very interventions that help an ACO or PCF practice succeed.
Reduced administrative burden in advanced models: Many of these models simplify or waive certain Medicare billing rules. For example, in ACOs, some telehealth restrictions are waived, and documentation may be simplified when there’s partial capitation. APCM similarly reduces admin burden by removing minute-to-minute accounting. CMS is aware that overly burdensome requirements can stifle innovation, so across the board there’s a trend of “Patients Over Paperwork.” The 2025 rule changes (like eliminating G0511 and simplifying code use for FQHCs, or removing time logs for APCM) are concrete examples of reducing paperwork to encourage adoption[6][70].
Support for practice transformation: CMS is not just dangling carrots; they are also providing technical assistance and resources. ACOs have learning system support, and models like PCF had care management fees paid in advance. Additionally, by codifying certain practices (e.g. requiring a care plan or 24/7 access in APCM), CMS is effectively guiding providers on what high-quality primary care looks like. Providers who align with this vision may also find alignment with private payers and Medicaid programs, which often follow Medicare’s lead.

In conclusion, the strategic goal is clear – CMS wants providers to adopt advanced primary care approaches that lead to better patient outcomes and lower costs. Whether through fee-for-service innovations like APCM or alternative payment models like ACOs and PCF, the agency is offering incentives and removing barriers for providers to make this shift. Hospitals and FQHCs should take note: embracing these programs not only improves reimbursement in the short term (via new codes and potential bonuses), but also positions your organization for success in the evolving landscape where value-based contracts and primary care excellence will drive financial sustainability.

Conclusion: Preparing for 2025 and Beyond

The year 2025 marks an inflection point in Medicare’s evolution toward value-based, primary care-centered health care. Advanced Primary Care Management (APCM) encapsulates Medicare’s commitment to supporting providers in delivering comprehensive, coordinated care. By aligning payment with patient needs and outcomes, CMS is actively encouraging hospitals, practices, and FQHCs to break from the volume-driven status quo. The new APCM codes, updates to CCM/PCM billing, integration of telehealth, and linkages to ACO models all serve a unifying purpose – to make primary care more effective and rewarding.

For hospitals and FQHCs, the message is: meet CMS halfway by enhancing your primary care capabilities. Leverage the new reimbursement for care management to invest in care teams. Streamline your workflows to take advantage of the reduced admin burdens (no more meticulous time logs for those in APCM). Educate your providers about the requirements and help them see the upside – improved patient satisfaction, more manageable chronic disease panels, and potential financial bonuses for quality care. Align your organizational strategy with CMS’s language of “access, quality, coordination, and equity.” This might include expanding after-hours access, deploying community health workers, implementing data analytics for population health, and forging partnerships (e.g. with behavioral health providers or community organizations) to address holistic patient needs.

Crucially, tie these efforts to the incentives on the table: monthly APCM payments, shared savings from ACO participation, avoidance of MIPS penalties, etc. CMS is offering resources to those willing to transform – take advantage of them. Also, stay informed: 2025’s changes are not the end, as CMS will continuously refine these programs (they even solicited feedback on developing hybrid payment models beyond APCM[83]). By adopting the spirit of advanced primary care now, hospitals and FQHCs will be well-prepared for future evolutions, such as potential partial capitation or expanded value-based models.

In summary, Advanced Primary Care Management in 2025 is both a opportunity and a challenge. It represents Medicare’s acknowledgement that primary care providers need better support and less hassle to do the right thing for patients. The onus is on providers to seize this opportunity – to align with CMS’s strategic goals of high-quality, preventive, coordinated care. Those who do so will not only enhance their Medicare reimbursements but, more importantly, will deliver the kind of care that keeps patients healthier and hospitals less crowded. The advanced primary care journey is gaining momentum, and CMS is actively clearing the path for providers to join. As we head into 2025, what hospitals and FQHCs need to know is that embracing APCM and its related programs is a savvy move that aligns clinical excellence with financial viability in the new era of value-based healthcare[7][2].

[1] [2] [3] [6] [7] [8] [9] [14] [17] [22] [39] [41] [42] [45] [48] [49] [52] [55] [56] [57] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [80] [83] Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule | CMS