APCM changed the game in 2025: instead of paying for logged minutes, Medicare pays a flat monthly fee for delivering advanced primary care — stratified by patient complexity. No 20-minute thresholds. No time audits. Just a defined set of capabilities you must actually deliver, every month. Sansera tracks and proves every one of them automatically.
APCM bundles the spirit of CCM, PCM, and transitional care into one monthly payment made to the practitioner who holds the patient's primary-care relationship. Payment is earned two ways: by tier, and by delivery.
| Code | Tier | Who qualifies | ~2025 rate* |
|---|---|---|---|
| G0556 | Level 1 | 1 chronic condition or fewer | ~$15/mo |
| G0557 | Level 2 | 2+ chronic conditions | ~$54/mo |
| G0558 | Level 3 | 2+ conditions and QMB / dual-eligible | ~$117/mo |
*National averages; localized in-platform. Level 3 patients are QMBs — they can never be balance-billed cost-sharing, and our engine suppresses it automatically.
There's no time minimum — but there is a checklist. To bill APCM, your practice must deliver a defined set of capabilities each month, including: patient consent, an initiating visit for new patients, 24/7 access, continuity with a designated care team, comprehensive care management, a patient-centered care plan, transitions-of-care management, home- and community-based coordination, enhanced communication channels, population-level analysis, risk stratification, performance-measurement participation, and digital care tools.
Most practices can do these things. Almost none can prove they did them, per patient, per month. That's the real APCM problem — and it's a data problem, not a clinical one.
Sansera models each APCM service element as a monthly-verifiable object and collects the proof automatically from platform activity — the after-hours call that proves 24/7 access, the care-plan version that proves maintenance, the risk scores that prove stratification. At month close, either every element verifies and the claim goes out, or you get a gap report naming exactly what's missing.
Condition counts come from the AI-maintained condition registry; QMB/dual status comes from nightly eligibility checks. Tier changes are automatic, auditable, and never guessed.
APCM belongs to the practitioner holding the primary-care relationship — and it can't be billed alongside CCM, PCM, or TCM by the same practitioner in the same month. The platform detects competing billers from claims data and blocks conflicting submissions before they become denials.
Here's the nuance most practices miss: for a high-touch complex patient, time-based complex CCM (~$144/mo) can out-earn APCM Level 2 (~$54/mo). For a lighter-touch dual-eligible, APCM Level 3 (~$117/mo) with no time requirement usually wins. The right answer is per-patient and changes over time. Our Smart Billing Engine computes it every month — expected revenue × probability of meeting requirements — and switches programs only when the gain is durable, handling the consent and care-plan updates a switch requires.
If you're an FQHC or RHC, you lived through G0511 sunsetting and the move to billing individual care-management and APCM codes. The confusion is the point: the organizations that navigate the new code structure capture meaningfully more revenue per patient than the old bundled rate — and the ones that don't leave it behind entirely. Sansera's rules engine is versioned by CMS rule year, so code transitions like this — including the 2026 APCM behavioral-health add-ons (G0568–G0570) — are configuration updates, not consulting projects.
No — and anyone who tells you otherwise is selling a single-program tool. APCM wins on light-touch and dual-eligible patients; time-based CCM wins on complex, high-touch patients. The optimal program mix across a real panel is patient-by-patient, which is why we built an engine instead of a preference.
APCM includes a performance-measurement element that practices commonly satisfy through MIPS Value Pathways or ACO participation. We track your qualification pathway as one of the verified elements.
Yes. Remote monitoring programs layer on top of APCM the same way they layer on CCM — with independent documentation, which the platform enforces.
As of 2026, optional APCM behavioral-health add-on codes (G0568–G0570) can be billed alongside an APCM base code by the same practitioner. They ship in Sansera as rules-service configuration.
CCM, PCM, and APCM are mutually exclusive — every patient, every month, there's one compliant program that pays best, and it changes as the patient changes. RPM and RTM stack on top with rules of their own. The Smart Billing Engine evaluates all of it monthly: eligibility, expected revenue, delivery requirements, and every compliance gate — deterministic rules, never AI guesswork, with an evidence bundle behind every claim.
Thirty minutes. Bring your panel size and payer mix; we'll show you what your care-management program is actually worth, and what it takes to capture it without hiring anyone.
Someone from the Sansera team will reach out within one business day with a custom demo agenda built around your patient mix.