The three APCM service levels
CMS introduced three monthly APCM codes. The patient’s chronic-condition profile and, for G0558, Qualified Medicare Beneficiary status determine the service level. Always confirm the current definition and billing rules before use.
Amounts are illustrative planning estimates used by Compound Care, not guaranteed payment or a fee quote. Actual payment varies by year, locality, payer, participation status, adjustments, patient eligibility, and claim circumstances. Use the official fee schedule and your Medicare Administrative Contractor for billing decisions.
Code-level summary
Level 1
The base APCM level, including patients with zero or one chronic condition, subject to current CMS requirements.
Level 2
For a patient with two or more chronic conditions.
Level 3
For a patient with two or more chronic conditions who is also a Qualified Medicare Beneficiary.
Programs that fit around APCM
These services are not interchangeable. Each has its own eligibility, service, and documentation requirements. They are grouped here because Compound Care can support the operational workflow without implying that every service is billable for every patient.
Behavioral Health Integration
The 2026 general BHI add-on for qualifying behavioral-health care furnished with an APCM base code by the same practitioner in the same month.
Requires G0556, G0557, or G0558Preventive visits
Welcome to Medicare, initial AWV, and subsequent AWV opportunities. Compound can identify due patients and support outreach; the practice furnishes the visit.
Can coexist with APCM when both services are furnishedTransitional Care Management
Post-discharge management with required communication, medical decision-making, and a timely face-to-face visit. Treat it as an alternative pathway during overlap.
Do not model as blindly additive to APCMWhat can stack—and what should not
Model both when each service is separately furnished and documented.
G0570 is reported with an APCM base code by the same practitioner in the month.
Account for the overlapping service period instead of adding both headline values.
Use the program that matches the patient and practice model; do not double count.
APCM billing requirements
CMS requires patient consent, an initiating visit when applicable, and the capability to furnish the APCM service elements. Those elements include access and continuity, comprehensive care management, a patient-centered care plan, transition management, coordination, enhanced communication, population-level management, and performance measurement.
For the broader operating model, start with the APCM implementation guide. If the practice is moving from a time-based care-management program, compare APCM and CCM before redesigning the workflow.
- Confirm patient eligibility and current chronic-condition documentation
- Confirm consent and any applicable initiating-visit requirement
- Confirm the practice furnished all required APCM service capabilities
- Check incompatible or overlapping services and payer edits
- Use the current fee schedule for the billing locality
- Retain a reviewable record supporting the monthly service and final code
What the monthly record should support
Enrollment evidence
Consent, patient notices, initiating-visit status, and the responsible practitioner.
Patient complexity
The chronic-condition and QMB information used for the candidate service level, reviewed against current definitions.
Services furnished
Patient interactions, care-plan work, coordination, transitions, tasks, and outcomes that were clinically appropriate that month.
Human approval
The final code, conflicts or exceptions reviewed, approver, date, and disposition before claim submission.
How to verify APCM reimbursement
National figures are useful for planning, but actual payment can change by calendar year, locality, participation status, facility setting, payer, and claim circumstances. Use the current CMS Physician Fee Schedule search and applicable Medicare Administrative Contractor guidance for the billing location.
Model the business case from the practice’s eligible population, expected enrollment, service-level mix, operating cost, collection assumptions, and realistic completion rates—not by multiplying every Medicare patient by a headline rate.
A monthly APCM billing review
- Confirm the patient and practitioner. Recheck eligibility, attribution, consent, and initiating-visit status.
- Review the month. Confirm the practice maintained required capabilities and the record reflects the clinically appropriate services furnished.
- Check the candidate code. Validate condition count, QMB status, current definitions, overlaps, and payer edits.
- Approve or hold. A qualified practice reviewer makes the final coding decision and documents any exception before submission.
Programs to add when operations are ready
Chronic Care Management
A credible alternative for practices not using APCM, but it introduces clinical-staff minute tracking and should split—not expand—the APCM population.
Compare APCM and CCMRemote Patient Monitoring
A strong future add-on once connected-device logistics, data ingestion, clinical review, treatment-management time, and escalation coverage are in place.
Review CMS care-management resources