APCM billing software for Advanced Primary Care Management
Advanced Primary Care Management pays per calendar month with no minutes to count, but it still asks a practice to place every patient in the right level, prove consent and keep other care management claims out of the same month. Agnotic Technologies builds that logic into your EHR or care management software, to your requirements.
Last reviewed by the Agnotic Technologies engineering team
What does APCM billing software need to do?
APCM billing software runs Advanced Primary Care Management, HCPCS G0556, G0557 and G0558, as a monthly service with no minutes to count. It assigns each patient a level from chronic conditions and QMB status, records consent and the service elements, and holds back conflicting claims. Agnotic Technologies builds this logic into your EHR or care management platform.
Where do practices get stuck with APCM?
The codes are simpler than CCM on paper. The trouble starts when a practice tries to run them on software built for timed programs.
Timers built for CCM, not for APCM
Care management tools count minutes toward a threshold. APCM has no threshold, so a timer that blocks the claim until 20 minutes are logged stops valid APCM months.
Levels set once and never revisited
A patient enrolled at Level 1 adds a second chronic condition, or gains or loses QMB status, and the claim keeps going out at the old level.
QMB status unknown at billing time
Level 3 depends on Qualified Medicare Beneficiary status, which lives in Medicare eligibility data, not in the chart. Practices that cannot see it default to Level 2.
Consent that cannot be found
The patient must be told that only one practitioner can bill the service each month, that they can stop at any time and that cost sharing may apply. A verbal yes with no record does not hold up.
Two care management claims in one month
The same practitioner bills APCM and also CCM, PCM, TCM or an e-visit for that patient in the same month, and one of the claims should never have gone out.
No proof of the service without minutes
With no time log, the record of what the care team actually did each month is the only evidence. Many systems keep it in free text nobody can report on.
What do we build for APCM?
Agnotic Technologies builds APCM features into the EHR, care management platform or billing system you already run, or as a separate service beside them. These are the features we typically build, shaped to your workflow.
Level assignment from the problem list
Rules that count active chronic conditions and read QMB status, propose G0556, G0557 or G0558 each month and show the clinician why.
QMB status from eligibility checks
Medicare eligibility responses (X12 270/271) parsed for QMB status and stored with the month they were checked, so Level 3 rests on data.
Consent capture and stop requests
A consent record with the four points the code descriptor lists, and a stop request that ends billing at the end of the calendar month.
Monthly APCM claim builder
One claim per patient per calendar month for the practitioner who holds the care management role, built without any minute threshold.
Same-month conflict edits
Edits that hold CCM, PCM, TCM, virtual check-in, e-visit and interprofessional consultation claims from the APCM practitioner in an APCM month, while allowing other practitioners' claims.
Service element evidence log
Structured entries for care plan updates, transition follow-ups, secure messages and coordination calls, so each billed month has a record behind it.
Behavioral health add-on handling
Support for the CY 2026 add-on codes G0568, G0569 and G0570, attached only when the same practitioner bills an APCM base code that month.
Population and gap reports
Risk stratification and care gap lists across the APCM panel, which the service elements ask the practice to maintain.
Which APCM level applies to each patient?
The level follows the patient's chronic conditions and QMB status, not the time spent. The table shows the data the software needs for each level and the evidence worth keeping every month.
CMS points practices to the Medicare HETS 270/271 eligibility transaction, and to the remittance advice, to see QMB status. We build the check to run before each claim month, so a lapse moves the patient to Level 2 instead of producing a wrong Level 3 claim.
| Level and code | Patient criteria | Data the software needs | Evidence kept each month |
|---|---|---|---|
| Level 1, G0556 | One chronic condition or fewer, expected to last at least 12 months or until death and placing the patient at significant risk | Active problem list, consent record, initiating visit date | Consent on file, the service elements furnished that month, care plan updates where clinically relevant |
| Level 2, G0557 | Two or more such chronic conditions | Count of qualifying active conditions, consent record, initiating visit date | As Level 1, plus the condition list used to set the level that month |
| Level 3, G0558 | A Qualified Medicare Beneficiary with two or more such chronic conditions | QMB status from a Medicare eligibility check, condition count, consent record | As Level 2, plus the eligibility response that showed QMB status for that month |
How is APCM billed differently from CCM and PCM?
APCM is billed once per calendar month by the one practitioner who takes on the care management role for that patient. Its code descriptors name no minimum time, so the claim does not wait for a timer.
CCM and PCM still run on time thresholds. A practice that offers both models needs software that knows which model each patient is on in a given month. For the timed programs, see our comparison of PCM vs CCM care management codes.
Not every element has to happen every month. A patient with no hospital stay that month needs no transition follow-up, but the practice must be able to furnish every element whenever the patient needs it.
Practices billing APCM also report the Value in Primary Care MIPS Value Pathway, so quality reporting belongs in the same build plan.
Which service elements must the practice be able to provide?
The code descriptors list the elements below. Each one turns into a feature or a record in the software.
Consent
Tell the patient about the service, the one-practitioner rule, the right to stop and cost sharing, and document that consent was obtained.
Initiating visit
A qualifying visit starts the service for new patients and for patients not seen within 3 years.
24/7 access and continuity
A way to reach the care team for urgent needs at any hour, and a designated team member for routine follow-up appointments.
Comprehensive care management
Systematic medical and psychosocial needs assessment, preventive service tracking and medication reconciliation.
Electronic care plan
A patient-centered care plan the team can update, shared inside and outside the practice and given to the patient. Our CCM care plan guide maps its sections to FHIR R4.
Care transitions
Follow-up after an emergency visit or discharge, within 7 calendar days of discharge as clinically indicated, with timely exchange of health information.
Enhanced communication
Secure messaging, portal access, virtual check-ins and e-visits so the patient can reach the team between visits.
Population-level management
Analyze panel data for care gaps and risk stratify patients by diagnoses, claims or other electronic data.
Performance measurement
Assessment on primary care quality, total cost of care and use of certified EHR technology.
Where does APCM software fail?
These are the failure points we design against when we add APCM to a care management or billing system.
- Level drift: the level stays fixed after a new chronic diagnosis, a resolved condition or a change in QMB status.
- QMB status assumed: Level 3 billed from an old eligibility response, or Level 2 billed because nobody checked.
- Missing consent: the service starts before consent is documented, or the record lacks the one-practitioner and cost sharing notice.
- Stop requests ignored: a patient stops the service but billing continues past the end of that calendar month.
- Same-practitioner conflicts: CCM, PCM or TCM from the APCM practitioner goes out in the same month.
- Over-blocking: edits that stop a specialist's TCM claim, which another practitioner may bill in the same month.
- Timers left switched on: APCM months held back because a CCM-style minute threshold was copied into the rule set.
- No initiating visit: a new patient, or one not seen in 3 years, enrolled without the qualifying visit.
What changed for APCM in CY 2026?
The CY 2026 Physician Fee Schedule final rule added three behavioral health add-on codes for APCM: G0568 and G0569 for psychiatric collaborative care and G0570 for general behavioral health integration. They are billed only with an APCM base code from the same practitioner in the same month, and they do not require counting minutes.
Rural health clinics and FQHCs bill APCM with the same three G-codes, paid in addition to the otherwise billable visit, as the CY 2026 rule restates.
The CY 2027 proposed rule, published in July 2026, asks for comment on whether a different APCM payment structure would work better. Nothing in it is final, so we keep the level and conflict rules configurable rather than hard-coded.
How does Agnotic build APCM into your software?
If a care manager already works a CCM queue, an AI chronic care manager agent can prepare the monthly review while staff make the decisions.
Map where the problem list, eligibility responses, consent and care plan live today, and which system sends the claim.
Write the level, consent and same-month conflict rules as configuration your billing team can review, not as code buried in the claim builder.
Build the features into your care management software or billing system, with the eligibility check through your X12 EDI integration.
Test each rule against past months of your own data before the first APCM claim goes out, then review rejections and denials with your billing team.
What do the fee schedule rules say?
Each fact is from the Physician Fee Schedule rule text published in the Federal Register, read on govinfo.gov.
The CY 2025 Physician Fee Schedule final rule established Advanced Primary Care Management services, HCPCS G0556, G0557 and G0558, billed per calendar month, and only one physician or practitioner may furnish and be paid for APCM for a patient in a month.
Source: CY 2025 PFS final rule, 89 FR 97710 (govinfo.gov)G0556 covers a patient with one chronic condition or fewer, G0557 a patient with two or more chronic conditions, and G0558 a Qualified Medicare Beneficiary with two or more chronic conditions.
Source: CY 2025 PFS final rule, APCM code descriptors (govinfo.gov)CMS finalized the APCM codes without specifying an amount of time that must be spent furnishing the services during the month.
Source: CY 2025 PFS final rule, section II.G.2 (govinfo.gov)CCM, PCM, TCM, interprofessional consultation, remote evaluation of patient images, virtual check-ins and e-visits may not be billed with APCM for the same patient in the same month by the practitioner furnishing APCM, but another practitioner may bill them when medically necessary.
Source: CY 2025 PFS final rule, concurrent billing (govinfo.gov)The CY 2026 Physician Fee Schedule final rule created add-on codes G0568, G0569 and G0570 for behavioral health integration, billed when the same practitioner reports an APCM base code in the same month.
Source: CY 2026 PFS final rule, 90 FR 49266 (govinfo.gov)
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Which standards does Agnotic build healthcare software against?
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through standards-based FHIR APIs.
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Where should you go next?
- PCM vs CCM care management codesHow the two timed care management programs differ and when each fits.
- Care management softwareShared care plans, care team queues and care program billing.
- Medical billing softwareCharge capture, claim edits and remittance built around your practice.
- CCM care plansThe sections a care plan needs and how they map to FHIR R4.
- Chronic care manager AI agentAn agent that prepares monthly care management reviews for staff.