In the CY 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule, CMS introduces a significant update to support the integration of behavioral health services within advanced primary care models. Specifically, the proposal outlines a new suite of G-codes, GPCM1, GPCM2, and GPCM3, intended to function as optional add-on services when billed in conjunction with APCM base codes (HCPCS G0556, G0557, or G0558) by the same practitioner during the same calendar month.
• GPCM1 is modeled after CPT 99492, capturing initial psychiatric collaborative care management.
• GPCM2 aligns with CPT 99493, supporting subsequent month CoCM services.
• GPCM3 reflects CPT 99484, which accounts for general behavioral health integration (BHI).
These add-on codes are designed to support team-based, integrated care delivery without the traditional burden of time-based documentation. Notably, CMS is not proposing a companion code to CPT 99494, which reflects additional time, due to the non-time-based nature of the APCM framework.
A key policy innovation in the proposed rule is CMS's consideration of removing beneficiary cost sharing, which is currently required under traditional Part B rules. This would be a huge win for providers as recent IMA feedback has suggested deep reluctance of patients consenting to these service due to the cost sharing component. Historically, services like Chronic Care Management (CCM) and Behavioral Health Integration (BHI) have faced underutilization, in part because of the 20% co-pay owed by patients. Recognizing this, CMS is explicitly requesting comment on whether these new codes should be treated as preventive services, a designation that would authorize the elimination of cost sharing altogether under the Social Security Act.
CMS points out that the structure and intent of the new APCM codes align closely with existing preventive service models. This approach signals a broader conceptual shift in CMS policy, redefining prevention not just as one-time screenings, but as ongoing, team-based care aimed at mitigating long-term risks and managing complex needs proactively.
Why It Matters for Primary Care Providers
The proposal represents a two-pronged strategy to enhance access and reduce administrative burden:
• Introducing monthly, predictable billing codes that are not time-based and reflect the intensity of managing chronic conditions.
• Exploring statutory pathways to remove cost sharing through preventive service designation, effectively increasing uptake and long-term patient engagement.
Unlike traditional care management codes, the APCM series allows for stratification based on the number of chronic conditions, making it both flexible and scalable for diverse practice types. We strongly encourage primary care providers and practice administrators to review and comment on these proposed changes.
CMS is seeking feedback on the following issues:
• Should cost sharing be waived when APCM bundles include both preventive and treatment services?
• Which preventive services (e.g., Annual Wellness Visit, depression screening) should be embedded within the APCM framework?
• Should CMS introduce new coding structures to more accurately capture primary care’s role in prevention and chronic care management?
• Would monthly prospective APCM payments be appropriate for Shared Savings Program ACOs, and how should these payments be reconciled?
• What patient consent protocols or safeguards should be built into APCM billing within ACO settings?
• What other policies would increase primary care participation in ACOs through APCM?
Comments are due by September 12, 2025
Public Comment Link: https://www.regulations.gov/commenton/CMS-2025-0304-0009