July 1, 2026 marks more than the start of a new quarter. It is the official launch date of the CMS Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model, a 10-year CMMI initiative that replaces time-based chronic care management billing with outcome-linked payments tied to actual clinical results. For medical coders and CDI teams, the shift matters immediately: once a beneficiary is enrolled, billing changes, documentation changes, and several familiar CPT codes are no longer appropriate for the duration of that care period.
The model opened to its first cohort on July 1, 2026 per CMS, with a second cohort starting January 1, 2027. Applications will be accepted on a rolling basis through early 2033. This is not a pilot with a small subset of providers — it is designed to scale.
What the ACCESS Model Actually Does
The ACCESS model restructures how CMS pays for chronic disease management in Original Medicare. Instead of billing per-minute codes like CPT 99490 (chronic care management, 20+ minutes) or 99491 (principal care management), ACCESS participants receive an Outcome-Aligned Payment (OAP) — a fixed annual per-beneficiary amount paid in monthly installments that covers integrated care management for qualifying chronic conditions. CMS withholds 50 percent of the OAP and releases it only after the participant demonstrates that at least half of attributed beneficiaries met defined outcome targets.
The model organizes care into four clinical tracks, each with its own qualifying conditions, outcome measures, and payment rates:
- Early cardio-kidney-metabolic (eCKM): Hypertension, obesity, prediabetes, dyslipidemia. Annual OAP: $360 (Initial Period), $180 (Follow-On Period). Rural beneficiaries add $15.
- Advanced CKM: Diabetes, atherosclerotic cardiovascular disease, chronic kidney disease. Annual OAP: $420 (Initial), $210 (Follow-On).
- Musculoskeletal: Chronic pain — low back, neck, hip, knee, upper extremity. Annual OAP: $180 (one period only, no Follow-On).
- Behavioral health: Depression and anxiety, measured by PHQ-9 and GAD-7. Annual OAP: $180 (Initial), $90 (Follow-On).
CMS Administrator Dr. Mehmet Oz described the model at its December 2025 announcement: “ACCESS introduces a way of paying for care that focuses on results. It offers clinicians a new predictable payment option, giving them the flexibility to use digital tools that help people take charge of their health.”
The Billing Code Shift: G-Codes Replace CCM CPT Codes
This is where coders need to pay close attention. ACCESS participants bill using ACCESS-specific HCPCS Level II G-codes rather than traditional CCM CPT codes. CMS is publishing finalized G-code descriptors and modifiers as part of the model; the exact code strings appear in the updated HCPCS Level II release, but the billing framework is unambiguous: once a beneficiary is aligned to an ACCESS participant, that participant bills ACCESS G-codes and receives monthly OAP installments rather than per-encounter CCM charges.
More critically, a substitute services list defines which CPT and HCPCS codes become restricted when a separate Medicare-enrolled provider furnishes overlapping care to an aligned beneficiary. For the behavioral health track, substitute services include digital health management device supply codes (G0552, G0553), psychiatric diagnostic evaluation codes (90791, 90792), remote therapeutic monitoring patient education and setup (98975), and initial psychiatric collaborative care management (99492). Billing any of these codes for an ACCESS-aligned beneficiary during an active care period triggers the Substitute Spend Adjustment, which reduces the ACCESS participant’s withheld OAP at reconciliation.
For outpatient billing teams, this means the standard question “what can we bill for this patient?” now requires an additional check: is this beneficiary aligned to an ACCESS participant for this condition? If so, the usual chronic care codes are off the table.
Documentation Is Now About Outcomes, Not Time
The most substantive practice change for CDI teams is what the documentation must prove. Under traditional CCM, the clinical note had to demonstrate that at least 20 minutes of non-face-to-face time was spent managing the patient’s chronic conditions. Under ACCESS, the documentation burden shifts entirely: it must establish a baseline measurement at enrollment (within 60 days) and then demonstrate actual clinical improvement at the end of the care period.
For the eCKM track, that means documenting a starting systolic blood pressure and proving that it either reached below 130 mm Hg or dropped by at least 15 mm Hg. For the CKM track, an HbA1c starting value is required, with the diabetes target set at either below 7.5% or a one-percentage-point reduction. For the musculoskeletal track, a validated patient-reported outcome measure — KOOS Jr. for knee, HOOS Jr. for hip, Oswestry Disability Index for low back, QuickDASH for upper extremity — must be completed at enrollment and again at follow-up. For the behavioral health track, a PHQ-9 or GAD-7 score of at least 10 is required to enter the Initial Period.
In short: if the documentation does not show where the patient started, the 50 percent withheld OAP cannot be reconciled favorably. This is a documentation standard closer to a clinical registry than to typical outpatient charting, and it requires coordination between the clinical team, CDI specialists, and the billing operation from day one of enrollment.
Where AI Fits In This New Workflow
ACCESS participants are required to use certified health IT and data infrastructure capable of tracking patient outcomes longitudinally, not just documenting an individual encounter. AI-assisted CDI tools are well-positioned here. Where a standard note might reference “hypertension managed,” an AI CDI workflow can flag that no baseline systolic value was recorded in the first 60 days, or that the end-of-period blood pressure reading was not linked to an enrollment baseline.
RAAPID, a risk adjustment AI firm, noted in its ACCESS analysis that AI can identify “where documentation fails to support the management of chronic conditions — for example, a patient with diabetes may have the diagnosis coded, but the documentation may lack evidence of ongoing monitoring, treatment adjustments, or outcome tracking.” That gap between a coded diagnosis and documented management is precisely the same gap that drives HCC undercoding risk in Medicare Advantage. ACCESS creates the same exposure in Original Medicare, and AI-assisted CDI is the same structural solution.
What Coders and CDI Teams Must Do Before July 31
The first baseline assessment window for July 1 enrollees runs 60 days from alignment — through late August. That is not much runway for organizations that have not already prepared. The priorities are concrete: confirm your encoder and charge description master reflect ACCESS G-codes as published by CMS; update billing workflow rules to route ACCESS-enrolled beneficiaries away from CCM CPT codes (99490, 99491, 99487, 99489) and to the G-code equivalents; alert co-treating providers to the substitute services list so no one inadvertently triggers the Substitute Spend Adjustment; and build a documentation template for each track that structures baseline and outcome fields as required data points, not optional addenda.
The reporting calendar is tight: baseline due by day 60, quarterly follow-up reports on a 70-to-110-day cycle, end-of-period outcome reporting by day 425. Early success reporting is permitted — up to 90 days early for eCKM and CKM tracks — and once an outcome is documented as achieved, it cannot be reversed by subsequent clinical worsening.
The model runs through June 30, 2036. A second cohort starts January 1, 2027, and major commercial health plans have signed a CMS ACCESS Payer Pledge to adopt similar outcome-based payment mechanics. The G-codes and outcome documentation standards introduced today may define how chronic care management is billed across payers for the rest of the decade.
Medikode’s automated medical coding platform is built to help coding teams adapt to exactly these structural billing shifts — from time-based CCM to outcome-linked G-codes, what the note has to prove changes, and the coding workflow has to change with it.