Focusing on Value-Based Care and Population Health

Editor's note: This is Part 6 of a 12-part series focused on optimizing medical group financial performance. Each brief in this series takes 2 to 3 minutes to read and identifies specific actions medical groups can take to achieve sustainable financial improvements.

Assessment

In recent years, CMS has prioritized preventive care, chronic disease management, and care coordination by introducing payments for services that support these objectives. Several key programs and reimbursement opportunities exist:

1. Annual wellness visits (AWVs): Intended to update a patient’s health history and create a personalized prevention plan.
2. Chronic care management (CCM): Allows providers to bill for non-face-to-face support services for patients with multiple chronic conditions.
3. Advanced Primary Care Management Program (APCMP): Introduced in 2025, this program offers three reimbursement levels based on patient care complexity.
4. Transitional care management (TCM): Encourages follow-up care after hospital discharge to prevent gaps and readmissions.
5. Remote patient monitoring (RPM): Focuses on patients with chronic conditions such as COPD, heart failure, or diabetes and is intended to reduce acute episodes and enhance care capacity.

The opportunity for each of these services can be assessed as follows:

AWV: Estimate the total Medicare patients on your primary care panels and multiply by the average reimbursement.  The CPT® codes are G0438 (initial) and G0439 (subsequent).  The reimbursement rate for a GPCI index of 1 is $160.44 for the initial and $126.47 for the subsequent.

CCM: Identify Medicare patients with two or more chronic conditions on your primary care panels and assume a 40% participation rate. Calculate the average monthly reimbursement based on expected usage of:  

• 99490: First 20 Minutes with a base rate* of $60.49
• 99439: Each additional 20 minutes with a base rate of $45.93
• 99491: 30 minutes provided by the billing provider with a base rate of $82.16
• 99487: First 60 minutes of complex care at a base rate of $131.65
• 99489: Each additional 20 minutes of complex care at a base rate of $70.52