Advanced primary care management (APCM): What the monthly service includes

A patient leaves an appointment with a plan. Over the next few weeks, they may have a question about a prescription, see a specialist, or need help arranging follow-up after a hospital stay. Their primary care practice helps connect those parts of their care.

Advanced primary care management (APCM) brings that ongoing support into a monthly Medicare service. It combines elements of care management and communication services, with the billing practitioner responsible for the patient’s primary care and serving as the main point of coordination.

For a practice considering APCM, the first question is what patients will receive and how the team will provide it.

What is advanced primary care management?

CMS describes APCM as a monthly bundle that draws on services such as chronic care management, transitional care management, and certain digital communications.

APCM has no monthly time threshold. Practices can report it once per patient per calendar month when the requirements are met. Documentation still needs to support the care provided.

Who can receive APCM services?

APCM can serve Medicare patients with different levels of need, including people with zero or one chronic condition. Higher service levels address patients with multiple qualifying chronic conditions, with a separate level for those who also have Qualified Medicare Beneficiary status.

The patient agrees that the participating practitioner will be their main point of ongoing primary care. Enrollment should begin with a conversation about what that relationship means: how to reach the team, what support is available, and how care with other providers will be coordinated.

What does the monthly service include?

Medicare’s patient guide to APCM describes support across several parts of a patient’s care:

Access to the care team. Patients and caregivers have a way to reach the team for urgent needs at any hour, alongside communication options such as secure messaging.

A current care plan. The electronic care plan brings together the patient’s needs, goals, and treatments. Care team members must be able to access and update it, and it must be available to other providers involved in the patient’s care, as appropriate. The practice must also give the patient or caregiver a copy.

Medication and preventive care support. The practice reviews medications, assesses care needs, and helps patients receive appropriate preventive services.

Coordination with other providers. Specialist care, referrals, and relevant home or community services are connected to the patient’s wider plan.

Support after a care transition. The team exchanges information and follows up when a patient moves between settings, such as returning home from a hospital.

The practice must be able to furnish the required elements. The work delivered to an individual patient depends on medical necessity and their needs; every element does not have to be performed every month. CMS clarifies this distinction in its APCM FAQs.

Consider a patient who raises a concern about medication costs. The team might help investigate an affordable option and bring any proposed treatment change to the clinician. In another month, that patient may return from a hospital stay with new instructions and need help understanding how those instructions fit their existing plan.

The service should adapt to those circumstances. A useful follow-up conversation begins with what has changed for the patient.

How is APCM different from CCM?

APCM and chronic care management share several activities, including care planning and coordination. Their eligibility and billing structures differ.

CCM is designed for patients with at least two chronic conditions expected to last at least 12 months or until death, with significant risk of serious deterioration or functional decline. Its billing codes have monthly time requirements that depend on the service and who provides it.

APCM can also serve patients with zero or one chronic condition. It uses a monthly bundle without a time threshold, with services tailored to the patient’s needs.

The practitioner’s role is another consideration. Under APCM, the billing practitioner is responsible for the patient’s primary care and serves as the main point of coordination. CCM can be provided by eligible primary care practitioners and some specialists managing qualifying chronic conditions.

The CMS chronic care management booklet explains CCM eligibility and time requirements and summarizes APCM’s service levels.

Practices should review patient needs, service requirements, and concurrent-billing rules before changing an existing care management arrangement.

What should be in place before the first month?

Start by explaining the service and obtaining documented consent. Patients need to know that only one provider can furnish and be paid for APCM in a calendar month, that they can stop participating, and that cost sharing may apply.

Confirm whether an initiating visit is required. Established patients may qualify for an exception based on recent visits or care management within the practice.

Medicare’s coverage information can help staff explain participation and potential costs to patients.

Practice readiness also includes identifying care gaps across the patient population, assessing risk, and meeting CMS performance-reporting requirements.

Before enrollment, walk through a few situations with the team. Who responds to a message received after hours? How does a hospital discharge reach the practice? Where can a covering clinician find the current plan? Working through these questions helps staff prepare for the care patients may need.

Where does behavioral health fit?

For 2026, CMS established optional APCM add-on codes for qualifying behavioral health integration and psychiatric collaborative care services. These are additional services with their own requirements, reported with an APCM base code by the same practitioner in the same month.

The 2026 Medicare Physician Fee Schedule fact sheet explains this addition. For a closer look at the clinical team involved, read our guide to the collaborative care model in primary care.

How HossCare supports APCM

HossCare’s advanced primary care service helps practices organize APCM requirements across their patient panel. Teams can see outstanding work, keep supporting documentation on the patient record, and prepare monthly claims for billing staff to submit.

Clinicians lead care, review recommendations, and sign notes. The platform supports the organization and documentation of that work within the practice’s EHR workflow.

Book a demo to see how HossCare can support APCM in your practice.