Advanced Care Management delivered. Zero extra work.
Advanced Primary Care Management (APCM) is Medicare’s monthly bundle for advanced primary care — care management, 24/7 access, and technology-based communication, paid once per patient per month instead of minute by minute. Doctorite runs the whole program for PCP clinics, including the behavioral health integration that makes it complete.
Seven things your clinic doesn’t have to build.
APCM only pays if the whole program actually runs. Doctorite delivers it as a managed service — so the requirements are covered without adding headcount or rebuilding your workflows.
Care management for Medicare patients
APCM is built around your Medicare panel. We identify eligible patients, confirm chronic condition and QMB status, and enroll them into a care management program that keeps running between office visits.
Turnkey delivery
The program arrives running. The AI virtual assistant handles consent, and care plans, outreach cadence, documentation, and reporting are configured and staffed for you — your clinicians keep seeing patients.
Eligibility verification to claims reimbursement
End to end: eligibility and QMB verification, consent on file, monthly service documentation, code selection across G0556–G0558 and G0570, claim submission, and reimbursement tracking.
Dedicated care navigators
Every enrolled patient gets a named navigator — the contact for urgent needs, the person who schedules successive routine appointments, and the continuity that APCM requires you to provide.
AI-generated SOAP notes, care plans & patient outcomes
AI drafts SOAP notes and care plans from every touchpoint and surfaces outcome trends across the panel — so documentation stays current and performance reporting becomes a byproduct of the work, not a separate project.
Additional revenue
A monthly bundle for each enrolled patient, billed once per calendar month — recurring reimbursement for care coordination your team is largely already delivering between visits.
Integrated with your EHR
Doctorite works alongside the system you already run. Care plans, transitions of care, and documentation flow into the record your team uses every day.
What is APCM?
Advanced Primary Care Management (APCM) fee-for-service billable services combine elements of several existing care management and communication technology-based services for Medicare patients.
The payment bundle reflects the delivery of the essential elements of advanced primary care.
What the bundle reflects
Principal, Transitional, or Chronic Care Management
The care management backbone of the bundle — the ongoing clinical work of managing a patient’s conditions between office visits.
Communication technology-based services
The non-face-to-face contact that keeps patients connected to the practice month to month.
- Monthly virtual check-insBuilt-in telehealth and communication tools for patient outreach
- Remote evaluation of pre-recorded patient informationIntegrated with your EHR for remote evaluations
- Interprofessional consultationsEmail and text communication between consulting professionals
An AI-powered APCM platform with the compliance functionality built in.
APCM services allow you to:
Match services to patient complexity
Provide patients with a wide range of services to meet their individual needs, scaled to how complex those needs are.
Bill a monthly bundle
Bill for these services using a monthly bundle — instead of billing for each individual service or recording care minute by minute.
Why APCM is worth running properly.
Care that continues between visits
Delivering APCM services helps patients access high-quality primary care beyond the office visit, addressing their needs more consistently on a monthly basis between appointments.
Stronger patient relationships
Improves patient satisfaction, engagement, and retention — patients stay connected to the practice rather than drifting between episodes of care.
Better chronic condition outcomes
Supports the clinic in managing chronic conditions, minimizing rehospitalizations, optimizing patient function, and minimizing decline.
How often, and under which codes.
Once per patient, per calendar month.
One monthly bundle — no minute-by-minute time tracking, no itemizing each individual service.
How Doctorite delivers this
APCM codes are built into the platform, reducing human error at billing time.
Single chronic condition
APCM services for a patient with one chronic condition.
Two or more chronic conditions
APCM services for a patient with two or more chronic conditions.
Two or more chronic conditions and QMB
APCM services for a patient with two or more chronic conditions who is also a Qualified Medicare Beneficiary (QMB).
General Behavioral Health Integration (BHI)
General BHI services for APCM patients, billable when a mental or behavioral health condition exists.
Covered by Doctorite’s behavioral health integration
What you must have in place to bill APCM.
To bill for APCM services, the following elements must be completed as and when clinically appropriate for the individual patient. Under each one, you can see how the Doctorite platform delivers it.
Get patient consent
Get written or verbal consent from the patient to participate in APCM services, and document it in the patient’s medical record. The consent must inform your patient that:
- Only one provider can furnish and be paid for APCM services during a calendar month
- The patient has the right to stop services at any time
- Cost sharing may apply to the patient
Consent must be obtained one time, before APCM services start.
How Doctorite delivers this
The AI virtual assistant reaches patients by voice and text, walks them through the required disclosures, captures verbal consent, and auto-records it in the chart — no consent forms to chase and no staff time spent collecting them.
Conduct an initiating visit (paid separately) for new patients
This visit is not needed if the same or another provider in the clinic has seen the patient:
- Within the past 3 years, or
- Provided another care management service (APCM, CCM, or PCM) to the patient within the past year
The Medicare Annual Wellness Visit (AWV) may qualify as the initiating visit if the provider who will be responsible for providing APCM care performs the AWV.
How Doctorite delivers this
Eligibility checks flag whether a new patient needs an initiating visit — reviewing visits within the past three years and any prior APCM, CCM, or PCM services — and the scheduler books one when it is required.
Provide 24/7 access and continuity of care
Including:
- 24/7 access for clinic patients or their caregivers with urgent needs to contact the clinic care navigator or another member of the care team
- Real-time access to the patient’s medical information
- The ability for the patient to schedule successive routine appointments with a dedicated care navigator
- Care delivery in alternative ways to traditional office visits, such as virtual check-ins
How Doctorite delivers this
Dedicated phone numbers and email communications connect patients to dedicated care navigators for timely access and response, with an appointment scheduler and reminders sent to patients for monthly check-ins.
Provide comprehensive care management
Including:
- Systematic needs assessments — medical and psychosocial
- Systems-based approaches to ensure receipt of preventive services
- Medication reconciliation, management, and oversight of self-management
How Doctorite delivers this
Comprehensive care assessments — medical, psychosocial, and behavioral health — completed on a monthly basis.
Develop, implement, revise, and maintain an electronic patient-centered comprehensive care plan
- The care plan must be available within and outside the billing practice, as appropriate, to individuals involved in the patient’s care
- Members of the care team must be able to routinely access and update the care plan
- The patient or their caregiver must receive a copy of the care plan
How Doctorite delivers this
AI-generated and clinician-reviewed care plans and SOAP notes, posted back into your EHR so the care team can access and update them — and sent to the patient by email.
Coordinate care transitions between and among health care providers and settings
Including:
- Referrals to other providers
- Follow-up after an emergency department visit
- Follow-up after discharge from a hospital, skilled nursing facility (SNF), or other health care facility
- Coordination of care transitions must include:
- Timely exchange of electronic health information with other health care providers
- Timely follow-up communication — direct contact, phone, or electronic — with the patient or caregiver within 7 days of discharge from an emergency department visit, hospital, SNF, or other health care facility, as clinically indicated
How Doctorite delivers this
Secure communication with your clinic to coordinate care transitions across referrals, emergency department visits, and discharges.
Coordinate practitioner, home-, and community-based care
You must provide ongoing coordinating communication and documentation on the patient’s psychosocial strengths, functional deficits, goals, preferences, and desired outcomes — from practitioners, home- and community-based service providers, community-based social service providers, hospitals, SNFs, and others.
How Doctorite delivers this
Care navigators capture the patient’s psychosocial strengths, functional deficits, goals, and preferences from everyone involved in their care, and keep that documentation flowing into the care plan and back into your EHR.
Provide enhanced communication opportunities
You must:
- Offer asynchronous, non-face-to-face consultation methods other than the phone — such as secure messaging, email, internet, or a patient portal
- Be able to conduct remote evaluation of pre-recorded patient information, and provide interprofessional phone, internet, or electronic health record (EHR) referral services
- Be able to use patient-initiated digital communications that require a clinical decision — such as virtual check-ins, digital online assessment and management, and evaluation and management (E/M) visits (or e-visits)
How Doctorite delivers this
Asynchronous, non-face-to-face channels — secure messaging, telehealth, and email.
Conduct patient population-level management
Such as:
- Analyze patient population data to identify gaps in care
- Risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients
How Doctorite delivers this
Patient- and clinic-level longitudinal outcomes that surface gaps in care and let you assess the efficacy of the APCM program.
Measure and report performance
Including assessment of primary care quality, total cost of care, and meaningful use of Certified EHR Technology (CEHRT), as follows:
- Report the Value in Primary Care MIPS Value Pathway (MVP)
- Participate in a Medicare Shared Savings Program Accountable Care Organization (ACO), Realizing Equity, Access, and Community Health (REACH) ACO, Making Care Primary model, or Primary Care First model
How Doctorite delivers this
Dashboards and reports your clinic can use for MIPS and other reporting requirements.
Can auxiliary personnel provide APCM services?
Yes.
Auxiliary personnel means individuals who are supervised by physicians or other billing providers to perform services incident to the provider’s professional services.
How Doctorite delivers this
Doctorite supplies the dedicated care navigators who deliver these services under your providers’ supervision.
Most of this runs without your staff touching it.
APCM programs stall on administrative load — consent, documentation, coding, outreach, reporting. Doctorite automates that layer, so your team stays on care and the compliance trail builds itself.
An AI virtual assistant obtains patient consent for you.
Consent is the first gate on every APCM claim — and the one that usually costs a clinic the most staff hours. Doctorite’s virtual assistant reaches patients by voice and text, walks them through the disclosures CMS requires, captures verbal consent, and writes it straight into the chart. No forms to mail, no calls to chase, no missing documentation at audit time.
- Explains that only one provider can bill APCM that month
- Confirms the patient’s right to stop services at any time
- Discloses that cost sharing may apply
- Auto-records consent in the patient’s medical record
SOAP notes and care plans drafted by AI
Every touchpoint becomes structured documentation, ready for clinician review rather than written from scratch.
APCM codes applied automatically
G0556–G0558 and G0570 are built in and selected per patient, so the right code lands on the right claim.
Eligibility and QMB verified up front
Chronic condition counts and QMB status are confirmed before enrollment, not discovered at denial.
Monthly outreach scheduled and reminded
Check-ins, follow-ups, and successive appointments are booked and reminded without anyone tracking a calendar.
Documentation posted back to your EHR
Notes and care plans flow into the system you already run, so nothing lives in a second place.
Dashboards and reports kept current
Outcomes, care gaps, and MIPS reporting update as the work happens, instead of being assembled quarterly.
APCM questions, answered
What does APCM stand for?
- APCM stands for Advanced Primary Care Management. It is a set of Medicare fee-for-service billable services that combine elements of several existing care management and communication technology-based services into a single monthly payment bundle.
How often can APCM be billed?
- APCM services are billed once per patient per calendar month.
What are the APCM codes for billing?
- G0556 for a single chronic condition, G0557 for two or more chronic conditions, G0558 for two or more chronic conditions plus Qualified Medicare Beneficiary (QMB) status, and G0570 for General Behavioral Health Integration (BHI) services for APCM patients when a mental or behavioral health condition exists.
Can auxiliary personnel provide APCM services?
- Yes. Auxiliary personnel means individuals who are supervised by physicians or other billing providers to perform services incident to the provider’s professional services. They can be employees, leased employees, or independent contractors of the billing provider.
This page summarizes Advanced Primary Care Management (APCM) services for general informational purposes and is not billing, legal, or compliance advice. Codes, coverage, and requirements are set by CMS and can change — confirm current guidance and your practice’s eligibility with CMS and your billing or compliance advisors before submitting claims.
Let’s stand up APCM at your clinic.
For more information on how APCM can benefit your clinic, please reach out to us or book a demo.