To implement Advanced Primary Care Management (APCM), a practice needs a consistent care team, patient consent, a shared electronic care plan, ways to communicate and coordinate care, and the applicable performance-reporting arrangements. Medicare pays for that continuing primary care in a monthly bundle, without a minute threshold for the APCM base service.
The 13 areas below unpack the ten core CMS requirement groups. Access, continuity, and alternative care delivery share one CMS group; population analysis and risk stratification share another. These are not thirteen tasks to repeat for every patient every month.
Some requirements are standing practice capabilities, some are services a patient receives when needed, and performance reporting has its own pathway. The CMS APCM FAQ, questions 4 through 6, explains that distinction, including why practice-level documentation does not need to be copied into every patient's chart.
1. Around-the-clock access to the care team
Patients and caregivers with urgent needs must be able to reach the practitioner or another care-team member 24/7. The person responding needs real-time access to the patient's medical information. Set up the people, contact instructions, and record access together so an after-hours question can lead to an informed response.
2. A consistent clinician and care team
The billing practitioner serves as the continuing focal point for the patient's primary care. Patients also need to be able to schedule successive routine appointments with a designated care-team member. Make the relationship clear to the patient and keep handoffs connected to the same plan.
3. Ways to deliver care beyond the traditional office visit
CMS includes alternative delivery arrangements, such as expanded hours or home visits. Put capabilities in place that fit your patients and their needs. The goal is access to appropriate care, not adding a separate encounter solely to complete a checklist.
4. Comprehensive care management
Assess medical and psychosocial needs, help patients receive preventive services, reconcile medications, and support self-management. The useful record connects what the team learned to what happens next: a medication question, a preventive service to arrange, or a goal to review.
5. An electronic, patient-centered care plan
Develop, implement, revise, and maintain a plan that reflects the patient's goals and needs. The care team must be able to access and update it routinely, and others involved in care need access as appropriate. Give a copy to the patient or caregiver. A plan is useful when it guides the next conversation, not when it sits in a folder.
6. Follow-up after care transitions
Connect referrals and facility-discharge information to the team handling follow-up. CMS calls for timely electronic information exchange and communication with the patient or caregiver within seven days of discharge from an emergency department, hospital, skilled nursing facility, or other health care facility, as clinically indicated. Make clear who receives the information and who acts on it.
7. Coordination with other practitioners and community services
Bring specialist, home-health, and community-service communication back to the patient's goals, preferences, and desired outcomes. Record the relevant information and follow-up so the next team member can continue the work rather than restart it.
8. Enhanced communication between appointments
Offer asynchronous options beyond a phone call, such as secure messaging, email, or a patient portal. The practice also needs the capability for remote evaluation of recorded patient information, interprofessional consultation, and patient-initiated digital care. Give patients clear channels and connect messages requiring a clinical decision to the appropriate person.
9. Documented patient consent
Obtain verbal or written consent before APCM begins and document it in the medical record. Explain that only one provider can furnish and be paid for APCM during a calendar month, that the patient can stop services, and that cost sharing may apply. Consent is obtained once, not collected again as a monthly task.
10. An initiating visit when required
Review the patient's history before scheduling a new visit. No initiating visit is needed if the practice has seen the patient within three years or provided APCM, CCM, or PCM within the past year. When required, the initiating visit is paid separately; an Annual Wellness Visit can qualify if performed by the practitioner responsible for APCM.
11. Population information that identifies gaps in care
Analyze the practice's patient data to find care gaps. Make the result actionable: identify the patients who need outreach, what the team is trying to address, and how the response returns to the record. This is a practice-level process, not another form to complete in every chart.
12. Risk stratification that targets services
Use defined diagnoses, claims, or other electronic information to direct services to patients. Keep clinical priority separate from the APCM billing level. G0557 requires two or more qualifying chronic conditions; G0558 adds QMB status. The conditions must be expected to last at least 12 months or until death and create significant risk of death, acute worsening, or functional decline. G0556 applies to patients with one or no chronic conditions.
13. The applicable performance-measurement pathway
Performance measurement covers primary care quality, total cost of care, and use of certified EHR technology. MIPS-eligible clinicians generally register for and report the Value in Primary Care MIPS Value Pathway. Qualifying model participation can satisfy the requirement, and the final Medicare rule describes the exceptions, including practitioners who are not MIPS eligible. The practice handles this reporting separately from an individual patient's APCM record.
How FairPath makes those responsibilities easier to run
The requirements become much easier to manage when the patient information, care plan, conversation, and supporting record stay together. FairPath supplies that workspace, including built-in condition checks and AI-assisted preparation, rather than asking the team to assemble a new set of spreadsheets.
On a small screen, swipe or scroll the table to see all three columns.
| Function | What your team owns | What FairPath records or surfaces |
|---|---|---|
| Conditions and level | The documented diagnoses and QMB information. | Qualifying-condition evidence, condition count, and a recommended APCM level. |
| Consent and visit history | The patient conversation and any required visit. | Consent status, recorded visit history, and the initiating-visit review. |
| Care plan | The patient's goals and clinician authorization. | A draft generated from conditions, clinical pathways, and patient context; the published plan and review dates. |
| Connected care | Staff coverage, responses, and clinical decisions. | Patient context, calls, messages, and readings when connected monitoring is in use. |
| Requirement review | The care delivered, open work, and final review. | Ten requirement groups with status, notes, evidence attachments, and Amy's AI assessment. |
The care-plan workflow is a good example of the difference. Select the patient's conditions and the organization's pathways, then generate a draft with goals, interventions, tasks, and escalation steps. The clinician edits, authorizes, and publishes it. The same plan is visible in the APCM requirements workspace, alongside the record used to review the program. See the care-plan builder.
For each requirement, staff can record a status, add the relevant note or evidence, and ask Amy to assess what is available and recommend next steps. That keeps the review close to the work instead of turning month end into a search for missing information.
- 1. Review conditionsSee qualifying diagnoses and the recommended level.
- 2. Draft the planUse clinical pathways and patient context.
- 3. Approve the careThe clinician edits, authorizes, and publishes.
- 4. Keep the recordConnect care, requirement status, notes, and evidence.
- 5. Review what is openFocus follow-up using the shared record and AI assessment.
Illustrative workflow, not a product screenshot. The team updates the record as the work occurs.
Operating the program as a practice or pharmacy partner
A practice can use its own care team or work with a pharmacy providing support under a services agreement. In the FairPath pharmacy partnership model, the clinic bills under the applicable program rules and the pharmacy is paid for its services. The shared workspace gives both teams the patient context and program record they need.
Choose the care model deliberately. The same practitioner cannot bill APCM alongside overlapping services such as CCM, PCM, or TCM for the same patient in the same month. The final rule permits a different practitioner to furnish medically necessary services, and RPM or RTM can complement APCM when appropriate. Connected monitoring brings useful readings into care; it is not an APCM requirement.
Removing minute thresholds does not remove the cost of searching, drafting, and compiling records. The real cost of RPM, APCM, and CCM explains why the workflow around care matters. That is the work FairPath is built to simplify.
Use the APCM operational guide for more detail and the existing readiness steps to organize your starting point.