Description: Provides patients with a wide range of services to meet their individual needs based on complexity.  Combines several elements of care management and communication.

Delivery Method: Face-to-face, phone or video

Who Can Bill? Physician, Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist.  Auxiliary staff (care team members) can provider services working under the general supervision of the incident to visit. 
 

  • Can be employees, leased employees, or independent contractors of the billing provider
  • Must not have been excluded from Medicare, Medicaid, or other federally funded health care programs by the Office of the Inspector General or had their Medicare enrollment revoked
  • Must meet any applicable requirements to furnish “incident to” services, including licensure, imposed by the State in which they provide the services
     
    APCM services are primarily for primary care specialties (internal, family, geriatric and pediatric medicine)
Payer
Code    
Billing Allowance  		Description
Requirements: Must complete elements when appropriate. You don’t have to provide all these services each month                                                                                 
MedicareG0556
 		Billed monthly with no-time thresholdPatients with one or fewer chronic conditions 
  • Patient Consent (verbal or written)
    • Must be received at least once and documented.
  • Initiating Visit
    • Conducted once within the past three years.  
    • Medicare AWV may qualify as the initial visit if the provider performed and will be responsible for APCM services.
  • 24/7 Access and Continuity of Care
  • Patient-Centered Comprehensive Care Management Services
  • Patient-Centered Care Plan
  • Management of Coordination of Care (transitions)
  • Enhanced communication opportunities
  • Conduct patient population-level management
  • Performance measurement   
     
G0557

Patient with 2 or more chronic conditions.   

  • Be expected to last at least 12 months or until death of the patient.
  • Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.  
G0558

Patients with two or more chronic conditions and who are Qualified Medicare Beneficiary 

  • Be expected to last at least 12 months or until death of the patient.
  • Place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

*For additional details regarding requirements please reference CMS guidelines*  

MICMT does not have expertise related to the Centers for Medicare and Medicaid services coverage decisions related to billing. The information contained on this site comes from publicly available sources of CMS information. Any needed clarification should come from CMS or their representatives/contractors. 

Reference Materials