The Centers for Medicare and Medicaid Services (CMS) issued the calendar year (CY) 2026 Medicare Physician Fee Schedule (MPFS) Proposed Rule (Proposed Rule) on July 14, 2025. The Proposed Rule includes important proposals to facilitate the addition of behavioral health integration (BHI) and collaborative care management (CoCM) services by physicians, practitioners, rural health clinics (RHCs), and federally qualified health centers (FQHCs) that provide advanced primary care management (APCM) to Medicare beneficiaries.
In this alert, we summarize the key proposed changes for healthcare providers and accountable care organizations (ACOs).
Behavioral health integration add-on codes for advanced primary care management
CMS proposes the creation of three optional G-codes (GPCM1, GPCM2, and GPCM3) to be billed as add-on services to APCM base codes (G0556, G0557, and G0558) when reported in the same month by the same practitioner. The proposed add-on codes are intended to support the integration and billing of complementary BHI or CoCM services with APCM, with the goal of promoting better patient health and preventing chronic disease.
The codes would also be considered a “designated care management service” incident to the billing practitioner’s professional services and, as such, could be provided by auxiliary personnel under the general supervision of the billing practitioner.
Code structure and valuation
CMS states that the services encompassed by the proposed optional add-on codes should be directly comparable to existing BHI and CoCM codes. CMS cross-walks each proposed optional add-on code to its corresponding BHI or CoCM Current Procedural Terminology (CPT) code values for both practice expense and work relative value units (RVUs). Specifically:
- GPCM1 mirrors CPT 99492, which is the CPT code for the first month of CoCM services
- GPCM2 mirrors CPT 99493, which is the CPT code for subsequent months of CoCM services, and
- GPCM3 mirrors CPT 99484, which is a CPT code for 20 minutes or more of BHI services.
CMS also proposes allowing RHCs/FQHCs to use the new add-on codes for APCM services. However, to implement this change, CMS states that it would need to modify current RHC/FQHC billing and payment policies for CoCM services.
Under existing policy, CMS requires RHCs/FQHCs to report CoCM services using a bundled CoCM code (G0512) and sets payment for the bundled services at the annual average of the national non-facility Medicare fee schedule rate for CoCM codes 99492 and 99493.
Under the CY 2026 proposal, RHCs/FQHCs would no longer use G0512 or be paid the bundled rate. Instead, RHCs/FQHCs would be required to bill using individual CoCM codes, and they would receive the national non-facility Medicare fee schedule payment rates set for such codes.
Documentation
CMS proposes removing the time-based documentation requirements for both existing BHI and CoCM codes, and will not impose these requirements for the proposed optional add-on codes. CMS cites the need for providers furnishing APCM services to be able to provide BHI and CoCM without the burden of documenting their time spent performing the service. Specifically, CMS reasons that many practices that develop interdisciplinary teams to provide APCM are the ones most likely ready to furnish BHI and CoCM services, and that introduction of the add-on codes will streamline processes.
CMS believes that removing the time-based documentation would facilitate a more holistic, team-based approach to care coordination. Further, CMS anticipates that reducing documentation requirements may make primary care practitioners more likely to offer and furnish BHI and CoCM services, thereby improving access for primary care patients.
Changes to the definition of “primary care services” for ACO beneficiary assignment
CMS proposes amending the definition of “primary care services” used for assigning beneficiaries to Medicare Shared Savings Program ACOs in two key ways:
- Inclusion of new BHI/CoCM codes: The Proposed Rule adds “Enhanced Care Model Management Services” to the definition of “primary care services.” These services are comprised of the optional add-on BHI and CoCM service codes – ie, Healthcare Common Procedure Coding System (HCPCS) codes GPCM1, GPCM2, and GPCM3. CMS believes that including such services in the definition will “increase the accuracy of assignment based on the provision of primary care by ensuring that all expenditures for BHI and CoCM are used to determine beneficiary assignment.”
- Deletion of Social Determinants of Health code: CMS proposes to delete HCPCS code G0136 for Social Determinants of Health (SDOH) risk assessment services from the definition of “primary care services,” arguing that existing evaluation and management (E/M) service codes already encompass the costs of the service, rendering payments for SDOH risk assessment services duplicative.
Next steps for stakeholders
CMS is actively seeking feedback on numerous proposals within the Proposed Rule. Interested stakeholders – particularly interdisciplinary care teams, primary care providers, and ACOs – are encouraged to submit comments to CMS, which are due by September 12, 2025.
Key areas for consideration and feedback include:
- CMS’s proposed valuation and direct cross-walking of the proposed APCM add-on codes to existing BHI and CoCM service codes. Stakeholders should consider evaluating whether the new add-on codes and the removal of time-based documentation requirements will streamline care delivery and billing practices.
- Proposed changes to the definition of “primary care services” for beneficiary assignment and prospective monthly payments to primary care providers by ACOs for APCM services.
- Whether CMS should consider: (1) new payments to Medicare Shared Savings Program ACOs for prospective monthly APCM payments to primary care practices that fulfill the APCM billing requirements, with payments reconciled under the ACO benchmark; and (2) additional changes to APCM policies, coding, and/or payments that would generate primary care providers’ interest in ACO participation.
CMS is also evaluating whether APCM services should be defined to include a blend of preventative and treatment services, given that CMS believes balancing these services is often necessary for effective care management.
CMS is seeking comments on whether it should include the annual wellness visit, depression screening, or other preventative services in the APCM bundles and, if so, how CMS should apply cost-sharing to APCM services – particularly given that cost-sharing obligations are waived for preventative services under Medicare.
Learn more
If you have questions about the Proposed Rule, related advocacy efforts, or need assistance evaluating the regulatory impact of the Proposed Rule and possible implications for your organization – or if you need assistance drafting and preparing comments to the Proposed Rule by September 12, 2025 – please contact your DLA Piper relationship partner, the authors of this alert, or any member of our Healthcare practice group.
