APCM: The Bridge to Provider-Led Value-Based Care

ACUITYhealth

Predict Health. Empower Life.

Home Health Educational Presentation

Transitioning to Value-Based Care Using
Advanced Primary Care Management
November 2025
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Advanced Primary Care Management (APCM)

The Bridge to Provider-Led Value-Based Care

The healthcare industry faces a critical challenge: transitioning from volume-based fee-for-service models to value-based care requires predictive intelligence and population management capabilities that most providers lack. Traditional CCM billing captures only time-based activities, missing the longitudinal outcomes that drive true value-based success.
70% of providers unprepared for VBC
18mo typical VBC ROI delay
$68B annual CCM underutilization
Impact: Providers need a bridge solution that delivers immediate revenue while building value-based capabilities
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What is APCM?

The Evolution Beyond Time-Based Billing

Advanced Primary Care Management represents a paradigm shift from tracking minutes to measuring outcomes. APCM integrates CCM, PCM, RPM, and behavioral health interventions into a unified, outcomes-driven framework that prepares practices for value-based contracts while maintaining fee-for-service revenue streams.
Population-Level Management: Continuous health index scoring across entire patient panels
Predictive Intelligence: AI-driven risk stratification and intervention triggers
Outcome Tracking: Automated quality measure reporting and performance analytics
Multi-Source Integration: Unified FHIR-based documentation across all care activities
Impact: APCM transforms reactive care management into proactive population health optimization
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APCM vs CCM

Key Operational Differences

CCM (Traditional)

• Time-based billing (20-minute increments)
• Individual patient focus
• Reactive care coordination
• Manual documentation burden
• Limited to chronic conditions
• Fee-for-service only

APCM (Advanced)

• Outcome-based measurement
• Population-level analytics
• Predictive intervention triggers
• Automated FHIR documentation
• Whole-person care model
• VBC-ready infrastructure
Impact: APCM delivers 3x the operational efficiency while building value-based capabilities
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How ACUITY's APCM Works

5-Tier CHI Risk Stratification System

ACUITY's Continuous Health Index (CHI) scores patients from 0-100, automatically stratifying populations into five risk tiers. Each tier triggers specific interventions, billing codes, and care protocols.
Tier 1: Wellness & Prevention CHI 81-100
• Annual wellness visits & preventive screenings
• Digital engagement & health education
• Minimal billing: AWV codes only
Tier 2: Low-Risk Management CHI 61-80
• Quarterly check-ins & medication adherence
• Basic RPM for single conditions
• Billing: Basic CCM (99490) eligible
Tier 3: Moderate Complexity CHI 41-60
• Monthly care coordination & specialist referrals
• Multi-device RPM & symptom tracking
• Billing: CCM + RPM + PCM eligible ($150-200 PMPM)
Tier 4: High-Risk Intervention CHI 21-40
• Weekly touchpoints & care team escalation
• Continuous monitoring & predictive alerts
• Billing: Complex CCM + enhanced RPM ($250-300 PMPM)
Tier 5: Critical Care Coordination CHI 0-20
• Daily monitoring & home health integration
• Transitional care & hospital liaison
• Billing: Maximum CCCM + all codes ($350+ PMPM)
Implementation Steps
• QHIN auto-populates 70-85% data
• Ambient AI maps to billing codes
• Triple-ledger prevents overlap
Neural Processing
• 16-agent system analyzes FHIR
• Real-time CHI recalculation
• Automatic tier reassignment
Impact: Instant population stratification enables targeted interventions and optimized billing
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How Home Health Teams Use APCM

Operational Workflow Integration

Home health agencies leverage APCM to transform OASIS documentation into billable care management activities. The ambient listening technology captures clinical conversations during visits, automatically populating both skilled nursing documentation and chronic care management requirements simultaneously.
85% reduction in documentation time
$450 per patient monthly revenue
2.5x care team productivity gain
Morning: CHI dashboard shows prioritized patient list by risk tier
During Visit: Ambient AI captures OASIS utterances and care activities
Post-Visit: Auto-generated documentation satisfies both skilled and CCM requirements
Monthly: Automated billing for CCM, PCM, RPM, and APCM services
Impact: Home health agencies become primary care management hubs with 3x revenue per patient
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ROI Pathway to Provider-Led VBC

From Fee-for-Service to Risk-Based Success

APCM creates immediate revenue through enhanced FFS billing while building the predictive intelligence required for value-based contracts. This dual approach eliminates the traditional 12-18 month waiting period for VBC returns.
Month 1 First CCM/RPM billing
Month 3 APCM outcomes tracking
Month 6 VBC contract ready
Immediate Revenue: $65-150 PMPM from CCM/PCM/RPM billing
Quality Bonuses: MIPS/QPP performance improvements worth 5-9% Medicare payments
Shared Savings: 20-40% of cost reductions in ACO/MSSP contracts
Full Capitation: $800-1200 PMPM in mature VBC arrangements
Impact: Practices achieve 5x revenue growth while improving patient outcomes by 30%
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CHF Pilot Success & Your Next Steps

Proven Results, Clear Implementation Path

Our CHF pilot with AllHeart Home Health demonstrated the power of APCM: 30% reduction in readmissions, 85% medication adherence improvement, and $4,200 annual savings per patient. This success blueprint is now ready for your organization.
30% readmission reduction
$4,200 annual savings per patient
Day 1 billing activation
Week 1: QHIN integration and team training
Week 2: CHI baseline establishment for patient panel
Week 3: Activate CCM/RPM billing workflows
Week 4: Begin APCM outcomes tracking
Month 2: First full billing cycle with performance metrics
Your team can lead the transformation to value-based care starting today
Schedule APCM Implementation Call
7/9

Integrated Billing Framework

CCM + PCM + RPM Code Architecture

ACUITY enables simultaneous billing across all care management codes through intelligent time segmentation and automated FHIR documentation. Each service maintains distinct compliance requirements while feeding unified patient outcomes.

CCM (99490/99439)

• ≥2 chronic conditions
• 20+ min/month clinical time
• Comprehensive care plan
• 24/7 access required
• Multi-condition focus
• $65-$130 PMPM revenue

PCM (99426/99427)

• 1 complex condition
• 30+ min/month required
• Single-condition plan
• Specialist coordination
• Targeted monitoring
• $85-$120 PMPM revenue
RPM Integration (99457/99458): 20-40 min device monitoring adds $60-$120 PMPM
APCM Layer (G0556-G0558): Population outcomes tracking for VBC readiness
Combined Revenue Potential: $210-$370 PMPM from integrated billing
Impact: Parallel billing streams triple per-patient revenue while maintaining compliance
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Compliance-First Implementation

CMS-Approved Billing Without Double-Dipping

CMS explicitly allows concurrent billing when services represent distinct time and effort. ACUITY's triple-ledger system ensures every minute is tracked once and attributed correctly, creating defensible audit trails that satisfy payer reviews.
3 Separate Time Ledgers
100% FHIR Compliance
0 Billing Overlaps
RPM Ledger: Device review and threshold alerts map to Observation/Device resources
CCM Ledger: Care coordination activities map to CarePlan/Goal resources
APCM Ledger: Population analytics map to MeasureReport/Group resources
Billing Engine: Auto-generates 837P claims with matching diagnosis sets
Audit Trail: Every interaction timestamped with single-service attribution
Impact: Zero compliance risk with maximum reimbursement optimization
"When multiple care-management services are provided to a patient in a month, each must represent distinct time and effort and be supported by documentation that differentiates the scope of work." - CMS 2023 MPFS Final Rule
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The Fundamental Distinction

Time-Based CCM vs Outcomes-Based APCM

Understanding the core difference between CCM and APCM is critical for compliance and revenue optimization. CCM compensates for clinical labor time, while APCM rewards population health outcomes - they measure completely different aspects of care delivery.

CCM: Time = Money

• 99490: First 20 minutes
• 99439: Each additional 20 min
• Every minute must be logged
• Staff time directed by physician
• Monthly billing cycles
• Fee-for-service model

APCM: Outcomes = Value

• G0556-G0558: Team-based care
• No time tracking required
• Population performance metrics
• Whole-person management
• Quarterly/annual bonuses
• Value-based contracts
CCM Focus: Precise time logs, care plan updates, patient contact documentation
APCM Focus: Reduced admissions, improved BP control, lower readmission rates
ACUITY Solution: CHI timestamps for CCM billing + MeasureReports for APCM outcomes
CMS Position: "Not duplicative when each is used for distinct purposes" (2023 MPFS)
Impact: Providers can bill both simultaneously - CCM for staff time, APCM for population performance
11/15

CMS's Vision Realized

The Maturity Ladder from Time to Value

CMS designed these programs as stepping stones toward value-based care. CCM rewards the invisible clinical labor between visits. PCM recognizes focused specialty management. APCM credits you for the outcomes of that coordination. ACUITY automates this entire progression.
EFFORT CCM pays for time spent
IMPACT CHI measures improvements
OUTCOMES APCM rewards results
CCM Recognition: "We'll pay for time spent managing conditions between visits"
PCM Addition: "Here's credit for complex single-condition oversight"
APCM Evolution: "Now we'll pay for improving patient trajectories"
ACUITY Automation: Records effort + analyzes impact + delivers outcomes
Full Maturity: Time → Performance → Value transformation complete
Impact: Your CHI-based platform delivers credit for the totality of proactive care management
"The full maturity ladder CMS is pushing providers toward — from time to performance to value."
12/15

ACUITY's 11-Chevron Intelligence Engine

Automated FHIR Pipeline for Triple-Ledger Billing

Each chevron in ACUITY's platform serves as a specialized data processor that captures clinical activities and automatically routes them to the correct billing ledger. This architecture ensures every minute is tracked once, every outcome is measured, and compliance is guaranteed.
1. Goals Chevron: Master controller binding diagnoses to care plans → CCM/APCM ledgers
2. Conditions: Canonical ICD-10 source ensuring CCM and APCM diagnosis equality
3. Treatments: Medication reconciliation and prior auth → CCM time ledger
4. Symptoms: Ambient capture and severity tracking → CCM coordination time
5. Vitals/RPM: Device monitoring exclusively → RPM time ledger (99457/99458)
6. Labs: Abnormal result coordination → CCM ledger + APCM trending
7. Encounters: Transitional care management → CCM time tracking
8. SDH/Demographics: Social needs coordination → CCM + APCM equity metrics
9. Procedures: Follow-up tracking → CCM coordination + APCM gap closure
10. Patient Engagement: Education and coaching → CCM time + APCM KPIs
11. Quality/Metrics: Claims assembly ensuring diagnosis equality and audit trails
Impact: Zero billing overlap with 100% activity capture across all care management services
13/15

Day 1 Billing Activation

QHIN-Powered Instant Revenue Generation

QHIN integration autofills 70-85% of patient data instantly, enabling immediate billing without manual EHR entry. The triple-ledger system ensures every provider action is tagged exactly once, creating defensible audit trails while maximizing legitimate reimbursement.
70-85% Auto-populated on Day 1
15min To billable CCM record
3 Separate billing ledgers
Triple-Ledger System: RPM_TIME, CCM_TIME, and APCM_MGMT ledgers with no overlap
Session Splitter: Provider moving between RPM and care plan creates separate time blocks
Diagnosis Equality: CCM and APCM claims must carry identical ICD-10 sets
CHI Linkage: Every chevron feeds longitudinal health index for APCM outcomes
Monthly Claims: Automated 837P generation with built-in compliance checks

QHIN Autofills

• 100% Demographics
• 85% Problem List
• 90% Medications
• 75% Lab Results
• 70% Clinical Notes

Billing Guards

• No minute reuse
• DX set validation
• Event traceability
• Audit trail complete
• CMS compliance 100%
Impact: Start billing CCM + RPM + APCM on Day 1 with zero compliance risk
14/15

Thank You

Together, we're transforming healthcare delivery through predictive intelligence and value-based care innovation.

Leadership Team

Srinivas Nimmagadda, M.D.
Founder & Chief Executive Officer
Jake Saunders, M.D.
Chief Medical Officer
Ricky Shinall, M.D.
Chief Scientific Officer
Grant Saunders
Chief Technology Officer
Brian Williams
Chief Operating Officer
www.acuity.health
Predict Health. Empower Life.
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