About this glossary
This glossary defines the programs, billing codes, eligibility categories, and roles that make up Medicare care management and remote care as of the 2026 Medicare Physician Fee Schedule. Terms are grouped by type — care-management programs, billing codes and policy, eligibility and coverage, and settings and roles — and each entry is written to stand on its own. Every reimbursement figure is a 2026 national average, rounded, and marked with “~”; actual amounts are set by your Medicare Administrative Contractor and vary by locality and year. Confirm current codes and rates with your MAC and current CMS guidance before billing.
Care-management programs
Advanced Primary Care Management (APCM). APCM is a Medicare payment model, introduced in 2025, that pays a flat monthly amount per patient for primary-care coordination based on patient complexity rather than on tracked minutes. It uses three levels — G0556, G0557, and G0558 — and, unlike time-based care management, requires no minute logs and can be furnished under general supervision. See the APCM program guide. (CareAtlas offers APCM-ready workflows; APCM is described here as available, not as a source of current CareAtlas outcomes.)
Chronic Care Management (CCM). CCM is a Medicare program that pays for non-face-to-face coordination of care for patients with two or more chronic conditions expected to last at least 12 months, requiring a documented care plan, patient consent, and tracked clinical time. The base code 99490 covers the first 20 minutes of clinical staff time per calendar month at ~$66 per patient per month (2026 national average, locality-variable). See the CCM program guide.
Principal Care Management (PCM). PCM is a Medicare program that pays for focused management of a single, serious chronic condition — rather than the two-or-more conditions CCM requires — expected to last at least three months. It is billed with codes 99424–99427 and uses tracked clinical time in the same way CCM does; the practical difference from CCM is condition count (one complex condition for PCM, two or more for CCM).
Remote Patient Monitoring (RPM). RPM is a Medicare program that pays for using an FDA-defined medical device to collect and transmit a patient’s physiologic data — such as blood pressure, weight, or blood glucose — to the care team for review and management. Core 2026 codes are 99453 (setup), 99454 (device supply, ~$52 per patient per month at 2026 national average, locality-variable), and 99457/99458 (clinical monitoring time). See the RPM program guide.
Remote Therapeutic Monitoring (RTM). RTM is a Medicare program that pays for monitoring non-physiologic therapeutic data — such as musculoskeletal or respiratory-system status, therapy adherence, and therapy response — reported by the patient or a device. It parallels RPM in structure (setup, device/data supply, and treatment-management time codes) but covers therapeutic rather than physiologic measures, and its codes may be billed by practitioners, including some who cannot bill RPM.
Transitional Care Management (TCM). TCM is a Medicare program that pays for managing a patient’s transition from an inpatient or other qualifying setting back to the community during the 30 days after discharge, requiring interactive contact within two business days and a face-to-face visit within 7 or 14 days. It is billed with 99495 (moderate complexity) or 99496 (high complexity). See the TCM program guide.
Behavioral Health Integration (BHI). BHI is a Medicare program that pays for integrating behavioral-health care into a primary-care setting, in which the treating practitioner and clinical staff manage a patient’s behavioral-health condition using a validated rating scale and a care plan. General BHI is billed with 99484; the Collaborative Care Model is the more structured, psychiatric-consultant-supported variant of behavioral-health integration.
Collaborative Care Model (CoCM). CoCM is a specific, evidence-based form of Behavioral Health Integration in which a primary-care team, a behavioral-health care manager, and a psychiatric consultant co-manage a patient using a registry and measurement-based treatment. It is billed with the time-based codes 99492, 99493, and 99494, and for RHCs and FQHCs it unbundles to these individual codes effective January 1, 2026.
Annual Wellness Visit (AWV). The AWV is a Medicare Part B preventive benefit that provides a yearly visit to create or update a personalized prevention plan and health risk assessment, billed as G0438 (initial) or G0439 (subsequent). It is not a head-to-toe physical, and under Medicare it carries no coinsurance or Part B deductible when furnished as a wellness visit; it is often the visit at which care-management programs are introduced and consent is obtained.
Billing codes & policy
G0511. G0511 was the single bundled HCPCS code that Rural Health Clinics and Federally Qualified Health Centers used to bill a mix of care-management services at one national rate. It is no longer payable for services on or after October 1, 2025 (a grace period ran through September 30, 2025); RHCs and FQHCs now bill the individual care-management codes on the UB-04, or move eligible patients to APCM. See the G0511 transition guide.
G0556 / G0557 / G0558 (APCM levels). These are the three HCPCS codes for Advanced Primary Care Management, billed once per patient per calendar month and tiered by complexity: G0556 (Level 1, one chronic condition, ~$16 per patient per month), G0557 (Level 2, two or more chronic conditions, ~$54), and G0558 (Level 3, Qualified Medicare Beneficiary / dual-eligible, ~$117). All figures are 2026 national averages, rounded, and vary by Medicare Administrative Contractor and locality.
G0568 / G0569 / G0570 (APCM behavioral-health add-ons). These are HCPCS add-on codes, effective January 1, 2026, that let a practice layer behavioral-health integration and Collaborative Care onto an APCM base payment for the same patient in the same month without the time-based rules of the standalone BHI/CoCM codes. Their national amounts are locality-variable; confirm current values with your Medicare Administrative Contractor before modeling revenue.
99490 (CCM). 99490 is the base CPT code for non-complex Chronic Care Management, covering the first 20 minutes of clinical staff time directed by a physician or other qualified professional in a calendar month for a patient with two or more chronic conditions. Its 2026 national average is ~$66 per patient per month, rounded and locality-variable, reflecting roughly a 10% increase over 2025.
99454 (RPM device supply). 99454 is the CPT code that pays for supplying a Remote Patient Monitoring device and its data transmission over a 30-day period, at ~$52 per patient per month (2026 national average, locality-variable). It is subject to the 16-day rule: the device must transmit data on at least 16 distinct days within the 30-day period for the code to be billable.
99495 / 99496 (TCM). 99495 and 99496 are the two CPT codes for Transitional Care Management following a discharge: 99495 covers a moderate-complexity transition with a face-to-face visit within 14 days, and 99496 covers a high-complexity transition with a face-to-face visit within 7 days. Both require interactive contact with the patient or caregiver within two business days of discharge, and both are billed once per 30-day post-discharge period; national amounts are locality-variable.
The “16-day rule.” The 16-day rule is the Medicare requirement that a Remote Patient Monitoring device must collect and transmit a patient’s data on at least 16 separate days within a 30-day period before the monthly device-supply codes (99454 for RPM, and the equivalent for RTM) can be billed. Falling short of 16 days of readings in the period makes the device-supply code non-billable for that period, which is one of the most common sources of denied RPM claims.
Medicare Physician Fee Schedule (PFS). The Medicare Physician Fee Schedule is the CMS-maintained schedule that sets the payment amount for each covered physician and practitioner service, updated annually through a final rule. Care-management and remote-care rates cited as “2026 national averages” come from the CY2026 PFS Final Rule (CMS-1832-F); the actual paid amount is the national value adjusted for local costs by the Medicare Administrative Contractor.
Medicare Administrative Contractor (MAC). A MAC is a private company under contract with CMS to process Medicare claims and set locality-adjusted payment amounts within a defined geographic jurisdiction. Because the MAC applies local adjustments to national Physician Fee Schedule values, the actual dollar amount a practice is paid for a given code varies by MAC and locality — which is why every rate in this glossary is marked as an approximate national average.
Eligibility & coverage
Qualified Medicare Beneficiary (QMB). A QMB is a low-income Medicare beneficiary enrolled in a Medicaid program that pays their Medicare premiums and cost-sharing, so Medicare providers may not bill a QMB for Medicare deductibles, coinsurance, or copayments. QMB status is one of the criteria that place a patient in the highest APCM tier (Level 3, G0558), reflecting the heavier coordination burden this population typically carries.
Dual-eligible. A dual-eligible individual is a person enrolled in both Medicare and Medicaid, with Medicaid helping cover Medicare premiums, cost-sharing, or benefits Medicare does not cover. Dual-eligible patients often have higher clinical and social complexity, and dual-eligible or QMB status is what qualifies a patient for APCM Level 3 (G0558, ~$117 per patient per month, 2026 national average, locality-variable).
Original Medicare vs Medicare Advantage. Original Medicare is the federal fee-for-service program (Part A hospital and Part B medical) in which patients can see any provider that accepts Medicare and services are billed directly to Medicare under the Physician Fee Schedule. Medicare Advantage (Part C) is Medicare coverage delivered through a private plan that contracts with CMS; care-management coverage and billing rules under Medicare Advantage are set by the plan and can differ from Original Medicare’s national codes and rates.
Hospital Readmissions Reduction Program (HRRP). HRRP is a Medicare value-based program that reduces payments to hospitals with higher-than-expected 30-day readmission rates for certain conditions, creating a financial incentive to prevent avoidable readmissions. It is a primary reason hospitals invest in transitional care management and remote monitoring after discharge.
Medical Decision-Making (MDM). MDM is the framework Medicare and CPT use to gauge the complexity of a clinical encounter — based on the number and severity of problems addressed, the data reviewed, and the risk of the management options — and it is one basis on which the level of many evaluation-and-management and care-management services is determined. Higher MDM complexity generally supports a higher-level (and higher-paying) code, provided the documentation substantiates it.
General vs direct supervision. Supervision level defines how physically present the billing physician or qualified professional must be while clinical staff furnish a service: direct supervision requires the physician to be in the same office suite and immediately available, while general supervision requires only that the service be furnished under the physician’s overall direction and control, without their physical presence. APCM and many 2026 care-management services allow general supervision, which is materially easier to satisfy in a rural clinic than direct supervision.
Provider of record. The provider of record is the enrolled clinician or entity that bills Medicare for a service and holds clinical responsibility for it. In care-management arrangements, the provider of record is the practice, health center, or affiliated physician-led professional corporation that furnishes and bills the service — not a vendor that supplies the supporting workflow.
Per patient per month (/patient/mo). “/patient/mo” denotes a payment made once per enrolled patient per calendar month, the billing basis for most care-management programs (APCM, CCM, and RPM device supply, among others). It is the standard way to express and compare care-management economics, because these programs pay a recurring monthly amount for each patient managed rather than a per-visit fee.
Settings & roles
Rural Health Clinic (RHC). An RHC is a Medicare-certified clinic located in a designated rural, medically underserved area that receives Medicare and Medicaid reimbursement under a special payment methodology intended to improve access to primary care. RHCs historically billed care management through the single G0511 bundle and, since that bundle’s October 1, 2025 sunset, now bill the individual care-management codes or offer APCM.
Federally Qualified Health Center (FQHC). An FQHC is a community-based health center that receives federal funding under Section 330 of the Public Health Service Act to provide primary care to underserved populations regardless of ability to pay, and that bills Medicare under a special prospective payment methodology. Like RHCs, FQHCs transitioned off the G0511 care-management bundle as of October 1, 2025 and now bill individual care-management codes or offer APCM.
Care navigator. A care navigator is a member of the clinical care-management team — a real, named person, not a chatbot or an app — who conducts a patient’s regular check-ins, coordinates services, and supports adherence to the care plan between visits, working under the direction of the billing clinician. In the CareAtlas model, care navigators use AI-assisted tools to surface patients who need attention, but clinicians direct the care and make the clinical decisions.
Management Services Organization (MSO). An MSO is a company that provides the administrative and operational infrastructure for medical care — such as staffing, technology, billing, and workflow — while the clinical services themselves are furnished and billed by a separate, physician-led professional corporation (PC). CareAtlas operates as an MSO: it runs the care-management workflow and platform, and the clinical services are delivered and billed by an affiliated physician-led PC, not by CareAtlas itself.
HealthQuilt. HealthQuilt is CareAtlas’s proprietary care-management platform, which reads structured data from the patient’s chart, surfaces the patients who need attention, and organizes the documentation a care-management claim requires. It is built human-first: HealthQuilt’s AI assists the care team by tracking data and suggesting insights, while care navigators deliver the human contact and clinicians make every clinical decision.
