Most Primary Care Clinicians Miss Out on Medicare’s New $1,292-a-Year Billing Codes

A year after Medicare rolled out its most generous billing codes ever for comprehensive primary care, only about 15 percent of primary care clinicians in a new national survey say they are actually using them. The finding, published in the Journal of General Internal Medicine, reveals a striking gap between the money now on the table and the clinicians positioned to collect it. Nearly half of the surveyed clinicians had never even heard of the codes, known as Advanced Primary Care Management, or APCM, despite the fact that the highest-paying tier could bring a practice more than $1,200 per Medicare beneficiary annually.

The study surveyed US primary care clinicians between December 4 and 11, 2025, roughly twelve months after the codes took effect in January 2025. The survey was fielded as part of a regular rapid-cycle survey series run by the Larry A. Green Center, which launched in March 2020 to study the impact of the Covid-19 pandemic on primary care clinicians and practices and has since addressed a variety of topical subjects. Of 568 respondents, 404 met the inclusion criteria for analysis: respondents not in patient care, those from practices not billing Medicare, and those who skipped the APCM section were excluded. The results suggest that the biggest obstacle is not resistance to the codes but simple unawareness. Of the 404 respondents, 176, or 43.6 percent, reported they had never heard of APCM codes at all. Another 168, or 41.6 percent, knew of the codes but cited a specific barrier preventing them from billing. Only 60 respondents, or 14.9 percent, reported using them.

Among those who knew about the codes but were not billing them, the most frequently cited administrative barrier was not understanding what documentation was required, named by 53.0 percent. Electronic health record problems came next at 38.1 percent, followed by administrative burden at 33.3 percent. Concern about patient cost-sharing was cited by 19.0 percent. Notably, the study found no significant differences in practice characteristics between users and non-users, although there was a non-significant trend toward greater use among clinicians participating in Accountable Care Organizations, at 20.3 percent versus 12.6 percent.

The payment structure explains why the low uptake matters so much. In 2025, the average Medicare allowed payment for APCM codes was $15.20 per month for a patient with one or fewer chronic conditions, $48.84 for a patient with two or more chronic conditions, and $107.07 for a patient with two chronic conditions who is dually eligible for Medicare and Medicaid. A clinician billing monthly for a patient in the highest payment tier would receive $1,292 over one year. Unlike earlier primary care codes, clinicians may bill APCM as often as monthly with patient consent, regardless of whether a visit occurred that month, and the required service elements may be delivered by the whole primary care team rather than the individual clinician.

Medicare deliberately designed APCM to lower the administrative hurdles that sank earlier reforms. Beginning in 2012, the agency introduced codes for transitional care management, chronic care management, and behavioral health integration to compensate for comprehensive primary care work not fully valued by standard evaluation and management visit payments. Claims analyses showed those codes saw low uptake, with administrative complexity and insufficient payment as the principal barriers. Billing the chronic care management code, for instance, requires documentation of time spent on services. APCM drops that requirement entirely, and Medicare does not require clinicians to formally attest or complete a certification process for the required practice capabilities. Participating in the Medicare Primary Care MIPS Value Pathway or a Medicare Accountable Care Organization program such as the Medicare Shared Savings Program, for example, satisfies the Measure and Report Performance criterion.

The contrast with the G2211 code, introduced in 2024, is instructive. G2211, billed alongside evaluation and management visit codes for medical care services that serve as the continuing focal point for all needed health care services, has minimal criteria beyond a continuity of care relationship and achieved 24 percent first-year uptake. But its payment is modest, about $16, and most first-year G2211 claims came from specialists rather than primary care clinicians. APCM, by contrast, restricts eligibility to physicians and non-physician practitioners responsible for all of a patient’s primary care services, yet first-year uptake in this survey landed in roughly the same range as G2211 despite the greater requirements for justifying the billing.

There is a historical silver lining in the data. The 14.9 percent uptake found in the survey is more than three times greater than the 4.2 percent of primary care practices that billed chronic care management codes during their first year of availability. Uptake of chronic care management and transitional care management codes increased modestly over the years following their introduction, and the authors suggest the same trajectory may unfold for APCM. Of the 60 clinicians in the survey who were already billing APCM, 58 percent reported that billing for the services had benefited their practice, an early signal that early adopters find the codes worthwhile.

The study carries important limitations that shape how the findings should be read. The survey relied on convenience sampling through social networking and crowdsourcing, with invitations distributed through more than 150 professional societies and organizations such as the Primary Care Collaborative, listservs, and practice-based research networks. Anonymity was maintained through unique tokens embedded in survey links and generated by respondents, allowing the researchers to detect unique respondents and track individuals answering more than one survey; 37 percent of the longitudinal cohort responded, and no denominator was available to compute a response rate for the non-cohort group. Respondents came from 47 states, and individual and practice characteristics generally aligned with the national population of US primary care clinicians, but women, White individuals, family physicians, clinicians practicing in rural areas, clinicians working in federally qualified health centers and other community health centers, and clinicians in residency teaching practices were over-represented. General internists, who tend to have a greater share of Medicare beneficiaries in their practices and may be more motivated to adopt new Medicare codes, were underrepresented, which could mean the survey underestimates true uptake. Overrepresentation of community health center clinicians could also produce an underestimate, since reliance on federally qualified health center prospective payments may lessen the incentive to bill additional codes. The measure of uptake was self-reported rather than drawn from Medicare Part B claims, so direct comparisons with claims-based studies must be made with caution.

Still, the survey method has a strength that claims analyses lack: it can capture why clinicians are not billing. The finding that nearly half of respondents were unaware of APCM points to what the authors describe as a major opportunity for Medicare, healthcare organizations, and professional societies to educate clinicians, including coaching on the relatively minimal documentation requirements and on strategies to make it easy to document and bill for APCM services in the electronic health record. The cost-sharing picture is more complicated. The highest tier code applies specifically to patients dually eligible for Medicare and Medicaid, who are exempt from cost-sharing in most states, but beneficiaries face cost-sharing for the two lower tier codes. Prominent reports have expressed concern that cost-sharing may deter patients from consenting to APCM billing and have recommended that Medicare waive it, though the authors caution their survey may not accurately reflect how much cost-sharing deters patients, since the question was framed as a reason for not using the codes rather than probed among current users, and clinicians may not be fully aware of their patients’ views during the early rollout.

The stakes extend beyond individual practices. Despite the addition of codes like chronic care management and transitional care management, and reduced documentation requirements for higher-level evaluation and management visits, the share of Medicare fee schedule spending devoted to primary care fell from 18.6 percent in 2017 to 15.9 percent in 2023. APCM is the most substantial of recent Medicare reforms intended to reverse that trend through flexible payment, and a recent report by the National Academies of Sciences, Engineering, and Medicine asserted that the codes test the boundary of Medicare’s authority to devise new fee schedule codes to more appropriately value primary care; further reform would require major restructuring through a hybrid primary care payment model that includes prospective payment in addition to fee-for-service. Whether APCM will rebalance Medicare spending toward primary care remains undetermined, but the authors are blunt about the arithmetic: that outcome is extremely unlikely unless uptake among primary care clinicians becomes far more widespread than the first year’s numbers show.

Subject of Research: Uptake and barriers to billing Medicare Advanced Primary Care Management codes among US primary care clinicians

Article Title: Primary Care Clinician Uptake of Medicare Advanced Primary Care Management Billing Codes

Article References: Grumbach, K., Duffy, C. M. C., Gonzalez, M., Stange, K. C., Greiner, A., & Etz, R. S. (2026). Primary Care Clinician Uptake of Medicare Advanced Primary Care Management Billing Codes. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10949-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10949-8

Keywords: Medicare, primary care, APCM billing codes, physician fee schedule, chronic care management, G2211, survey research, health policy, administrative burden, electronic health records, payment reform, Journal of General Internal Medicine