How the estimate works

APCM by tier

Your panel is split into G0556, G0557, and G0558 using the share of patients with two or more chronic conditions and the share who are Qualified Medicare Beneficiaries.

Behavioral health add-on

Patients receiving qualifying behavioral health care are modeled with the G0570 add-on, which is billed alongside an APCM base code.

Wellness visits

Patients due for a visit are spread across the Welcome to Medicare visit, the initial AWV, and subsequent AWVs.

Transitions, net of overlap

TCM episodes are added for monthly discharges, minus the APCM months they replace, so the estimate does not double count.

Read the result as a ceiling

Rates are national planning estimates. Real payment depends on your locality, the year, participation status, patient eligibility, and whether every requirement was met. The capture slider is the share of the eligible opportunity you expect to actually furnish, document, and bill.

  • Use your actual Medicare panel, not your total patient count
  • Pull chronic-condition and QMB shares from claims or your EHR if you can
  • Start with a conservative capture rate, then raise it once the program is running
  • Check rates for your locality in the CMS Physician Fee Schedule search

For the rules behind each program, read the APCM codes and reimbursement guide.