CMS Guidelines and Compliance for APCM

Eligibility Requirements for APCM

The Centers for Medicare & Medicaid Services (CMS) guidelines have set specific eligibility criteria for APCM services. To ensure compliance, it’s essential that practices verify which patients qualify for APCM and document patient consent before services begin. The CMS requirements for APCM eligibility are designed to ensure that the service targets patients who would benefit most from continuous, managed care.

• Primary care providers only: Only PCPs are eligible to bill for APCM services, as these providers are positioned to deliver holistic, longitudinal care to patients.
• Medicare beneficiaries: Patients must be Medicare enrollees to qualify for APCM. There are specific billing codes based on the level of patient complexity, including codes for patients with multiple chronic conditions and those with QMB status.
• Patient consent: CMS mandates that practices obtain and document patient consent for APCM. This consent must be documented in the patient's record to confirm that the patient understands the nature of the service and any associated codes.

APCM Billing Codes and Requirements

CMS has established several billing codes specifically for APCM, each reflecting the level of patient complexity and intensity of care:

• G0556: For patients with one chronic condition or fewer, reimbursed at approximately $15 per month.
• G0557: For patients with two or more chronic conditions, reimbursed at around $50 per month.
• G0558: For high-complexity patients with QMB status and two or more chronic conditions, reimbursed at approximately $110 per month.

Each code also requires that the physician or qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all health care services (i.e. the individual providing APCM services) make available the following elements as appropriate:

• Patient consent: Inform the patient of the availability of the service, that only one practitioner can furnish and be paid for the service during a calendar month, of the right to stop the services at any time (effective at the end of the calendar month), and that cost sharing may apply.
• Initiating visit: Initiation during a qualifying visit for new patients or patients not seen within 3 years.
• 24/7 access to care: Provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week.
• Continuity of care: Continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments.
• Alternative care delivery: Deliver care in alternative ways to traditional office visits to best meet the patient’s needs, such as home visits and/or expanded hours.
• Comprehensive care management: Overall comprehensive care management, including:
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    • Systematic needs assessment (medical and psychosocial)
    • System-based approaches to ensure receipt of preventive services
    • Medication reconciliation, management and oversight of self-management.
• Patient-centered care plan: Development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan with typical care plan elements when clinically relevant:
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    • Care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary’s care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver.
• Coordination of care transitions: Coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable:
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    • Ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care.
    • Ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated.
• Ongoing communication: Ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient’s psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient’s medical record.
• Enhanced communication opportunities: Enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary’s care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology-based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/EHR referral service(s), to maintain ongoing communication with patients, as appropriate:
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    • Ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and E/M visits (or e-visits).
• Population data analysis: Analyze patient population data to identify gaps in care and offer additional interventions, as appropriate;
• Risk stratification: Risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients;
• Performance measurement: Be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of Certified EHR Technology.

APCM Compliance Best Practices

Ensuring compliance with APCM requirements is critical for maximizing revenue and reducing the risk of claim denials or audits. CMS expects practices to meet high standards for documentation, patient engagement, and care plan management.

Best practices for APCM compliance:

• Use APCM-compliant software: APCM-compliant software simplifies the documentation and billing process by automating coding and sending compliance reminders for routine tasks.
• Regular staff training: Conduct regular training sessions for your care team to stay updated on APCM requirements, CMS guidelines, and best practices in documentation.
• Monthly compliance checks: Monthly checks of APCM documentation, billing, and care plan updates can help ensure that all activities align with CMS standards, minimizing the risk of compliance issues.

These compliance practices not only support APCM billing accuracy but also improve overall patient care by ensuring each patient’s needs are continuously monitored and addressed.