Advanced Primary Care Management (APCM): A Comprehensive Approach to Preventive Care
On a Tuesday morning, Dr. Patel’s first patient is a 67-year-old with hypertension, diabetes, and a history of heart disease. In the past, the visit might have been dominated by immediate concerns—renewing prescriptions, adjusting insulin doses, or managing an acute issue. Today, however, Dr. Patel’s practice operates under an Advanced Primary Care Management (APCM) model. The patient’s Annual Wellness Visit (AWV), Chronic Care Management (CCM), and Principal Care Management (PCM) have been coordinated in advance. Labs are already reviewed, medication adherence has been tracked, and follow-up appointments are scheduled. The result is a more proactive, prevention-focused conversation that gives space to address long-term health goals.
What is advanced primary care management?
Advanced Primary Care Management is a strategic model that integrates preventive and chronic care programs into a cohesive, year-round system. Instead of viewing AWVs, CCM, and PCM as separate services, APCM aligns them into a continuous care loop—each service sharing data, insights, and patient engagement with the others.
Beginning in 2025, CMS recognizes APCM services as a once-per-month bundled primary care service with specific billing and consent requirements. Practices that meet those requirements may bill the appropriate APCM HCPCS code, creating a formal structure for integrated preventive and chronic care.
The core components typically include:
- Annual Wellness Visits (AWVs): Yearly visits designed to identify risk factors, update preventive screenings, and create or revise a personalized prevention plan.
- Chronic Care Management (CCM): Monthly non–face-to-face coordination for patients with two or more chronic conditions expected to last at least 12 months (or until death), furnished under general supervision with specific documentation and care plan requirements.
- Principal Care Management (PCM): Focused management for patients with a single, serious chronic condition requiring intensive follow-up over at least three months, billed with PCM-specific CPT codes and documentation standards.
When integrated, these services form a multi-layered safety net—broad preventive coverage through AWVs, multi-condition oversight via CCM, and condition-specific intensity through PCM.
Why integrate AWVs, CCM, and PCM?
Running AWV, CCM, and PCM programs independently can yield benefits, but bringing them together under an APCM framework multiplies their impact—clinically, operationally, and financially.
Improved continuity of care
Without integration, patients can easily fall into gaps between visits. In APCM, each service is designed to feed into the next. For example, an AWV may reveal overdue screenings and uncontrolled A1C. CCM follows monthly to ensure screenings are scheduled, monitor home glucose readings, and support medication adjustments. If the patient develops a complication—such as a diabetic foot ulcer—PCM takes over with intensive wound care management, while CCM continues to manage the rest of the patient’s conditions. This ensures every problem is addressed at the right time and intensity.
Data synergy for better decision-making
AWVs provide baseline risk profiles and prevention plans. CCM and PCM add a steady stream of monthly updates: lab results, adherence checks, and patient-reported symptoms. Together, these create a dynamic record that shows trends over time—allowing providers to spot early warning signs, intervene before problems escalate, and personalize care more precisely.
Enhanced patient engagement
Patients experience APCM as an ongoing relationship rather than a series of disconnected encounters. Frequent, purposeful contacts—whether by phone, portal, or in person—signal that their health is being monitored year-round. This reinforces education, builds trust, and increases follow-through on screenings, medications, and lifestyle recommendations.
Operational efficiency and team-based care
With integration, each team member knows their role: medical assistants gather AWV risk data, nurses handle CCM outreach, and care coordinators focus on PCM cases. Shared documentation reduces duplication, and every staff member works from the same up-to-date information.
Positioning for value-based care success
Value-based care models reward outcomes, reduced avoidable utilization, and quality performance. APCM systematically closes care gaps, prevents hospitalizations, and documents results—directly supporting value-based incentives and shared savings opportunities.
Implementation strategy
Rolling out APCM successfully requires more than simply activating multiple programs, it’s a deliberate, phased process.
Phase 1: Build the AWV foundation. Start with AWVs to establish a prevention plan for each eligible patient. Train staff to use AWV templates efficiently and to flag chronic and high-risk conditions for follow-up.
Phase 2: Layer in CCM for eligible patients. From AWV results and EHR data, identify patients with two or more chronic conditions. Begin monthly outreach to educate, reconcile medications, and coordinate specialist care, ensuring documentation meets CCM requirements.
Phase 3: Add PCM for condition-specific intensity. For patients whose single condition dominates their care—such as advanced COPD or severe heart failure—launch PCM to deliver focused interventions alongside ongoing CCM oversight of other conditions.
Phase 4: Integrate workflows and technology. Link AWV, CCM, and PCM data within your EHR or a dedicated platform. Assign responsibilities clearly, track time accurately for CCM/PCM, and bill APCM as a monthly bundle when appropriate.
ROI and financial impact
When well-executed, APCM can deliver measurable financial and quality returns. Payment amounts vary by locality, payer, and annual updates to the Physician Fee Schedule (PFS), so practices should confirm current rates before projecting revenue.
*Illustrative national ranges. Confirm with the current-year PFS and local payer contracts.
For a panel of eligible patients, the combined services can yield stable revenue while helping meet quality metrics in value-based arrangements.
Common pitfalls and how to avoid them
Here is a number of potential pitfalls to bear in mind when implementing APCM:
1) Siloed workflows. If AWV, CCM, and PCM operate in isolation, integration benefits are lost. Centralizing coordination and maintaining shared documentation ensures seamless handoffs.
2) Under-enrollment. Eligible patients often aren’t offered these programs. Regularly run EHR reports to identify candidates and train staff to discuss program benefits during visits and outreach.
3) Compliance oversights. Missing consent, inadequate documentation, or double-counted time can result in denials or audits. Use structured workflows and system prompts to stay compliant. Remember: only one practitioner may bill CCM or PCM per patient per month, the same practitioner may not bill CCM and PCM for the same patient in the same month, APCM requires documented patient consent, including disclosure that only one provider may bill APCM each month.
Compliance and audit readiness
To maintain compliance:
- AWVs: Complete all required elements, including a Health Risk Assessment, and update the prevention plan. These visits are not physical exams.
- CCM/PCM: Document consent, maintain a comprehensive electronic care plan, and track time to meet CPT thresholds. Follow concurrency rules.
- APCM: Bill once per month when requirements are met. Consent must include the “one provider per month” disclosure and cost-sharing notice.
Lara Health unites AWV, CCM, and PCM workflows in one platform, fqcilitiates eligibility checks, ensures documentation is audit-ready, and provides dashboards to monitor performance in real time.
Conclusion
Advanced Primary Care Management transforms prevention and chronic disease management from a series of separate services into a coordinated, proactive system. By integrating AWVs, CCM, and PCM, and leveraging APCM when appropriate, practices can maintain continuous patient engagement, close more care gaps, improve outcomes, and strengthen their position in value-based care. Ready to transform your approach to prevention and chronic care? See how Lara Health makes APCM seamless, compliant, and impactful.
FAQs
What is Advanced Primary Care Management (APCM)?
An integrated care model combining preventive and chronic care services (AWVs, CCM, and PCM) into a continuous, coordinated approach.
Can APCM work for commercial insurance patients?
Yes. Many private payers reimburse for AWVs, CCM, and PCM, though requirements and rates vary.
Is it better to start all services at once?
Not always. Many practices start with AWVs, then add CCM and PCM in phases for smoother rollout.
How does APCM support value-based care?
It systematically closes care gaps, reduces complications, and documents performance—helping meet quality metrics and achieve shared savings.
Does Lara Health offer technology for APCM?
Yes. Lara Health integrates, documents, and manages AWV, CCM, and PCM in one platform.
Sources
CMS — Advanced Primary Care Management Services. 2025
Medicare.gov — Yearly “Wellness” visits. 2025
CMS — MLN909188 Chronic Care Management Services. 2025
CMS — Care Management resources (PCM codes)
CMS — Chronic Care Management FAQs. 2022
CMS — CY2025 PFS Final Rule Fact Sheet. 2024
