G0557 and G0558: what they pay, who qualifies, and what CMS asks for

G0557 and G0558 are two of the three Advanced Primary Care Management codes CMS created in 2025. Both pay a flat monthly amount for care management, with no minimum time to track.

They’re also the two tiers that carry most of the revenue. Here’s who qualifies for each, what they pay, and what CMS asks you to do in return.

The three APCM codes at a glance

• G0556: one or fewer chronic conditions. $16.37 a month.
• G0557: two or more chronic conditions. $53.77 a month.
• G0558: two or more chronic conditions, and the patient is a Qualified Medicare Beneficiary. $117.23 a month.

Those are 2026 Medicare Physician Fee Schedule national rates, before geographic adjustment. All three went up from 2025, when AAFP lists them at $15.20, $48.84 and $107.07. Your own rate moves with your locality, and you can see your specific rate here CMS Physician Fee Schedule Look-Up Tool.

G0557: two or more chronic conditions

G0557 is for a Medicare patient with two or more chronic conditions.

CMS defines a chronic condition as one expected to last at least 12 months, or until the patient’s death, that puts the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

That describes a big share of the patients a primary care team already manages between visits.

G0557 pays $53.77 a month at the 2026 national rate. That’s about $645 a year per patient.

Normal Part B cost sharing applies. The patient’s deductible and coinsurance count, so tell them when you ask for consent.

G0558: the same patient, plus QMB status

G0558 covers the same clinical picture as G0557. The difference is the patient’s coverage: they’re a Qualified Medicare Beneficiary.

QMB is one of the Medicare Savings Programs. The state Medicaid program pays the patient’s Medicare premiums, deductibles and coinsurance, so there’s no cost-share conversation with the patient.

Not every dual-eligible patient is a QMB. Some get partial help from Medicaid through other programs. Check QMB status, not just dual status, before you assign the code.

G0558 pays $117.23 a month at the 2026 national rate. That’s about $1,407 a year per patient.

What you don’t have to do: count minutes

Neither code has a monthly time threshold. Nobody has to log minutes, and there’s no 20-minute line to clear before you can bill.

That’s the biggest difference from Chronic Care Management. We walked through it in How is APCM different from CCM?, and ran the dollars in APCM or CCM: which one pays more for your patient?

What you do have to do

APCM pays for a set of capabilities. CMS lists them on its APCM page, and the main ones are:

• Patient consent, once, written or verbal, documented in the chart. It has to tell the patient that cost sharing may apply.
• An initiating visit, but only for patients who are new to the practice. It isn’t needed if you’ve seen the patient in the last three years, or given them another care management service in the last year.
• 24/7 access to the care team, and continuity of care.
• Comprehensive care management, with an electronic care plan that’s kept up to date.
• Coordination of care transitions, and with other practitioners and home and community-based services.
• Enhanced ways for the patient to reach the care team.
• Population-level management of your patient panel.
• Performance measurement and reporting.

You don’t have to deliver every element to every patient every month. In CMS’s words, you complete them when they’re clinically appropriate for the individual patient.

What you can’t bill in the same month

APCM, CCM and TCM can’t be billed by the same clinician for the same patient in the same month. APCM bundles chronic and principal care management, transitional care management and several communication-based services.

A patient can still move between programs from one month to the next. That’s what makes the choice between APCM and CCM a patient-by-patient decision.

New for 2026, three behavioral health add-ons can be billed alongside APCM: G0568 and G0569 for collaborative care, and G0570 for general behavioral health integration.

FQHCs and rural health clinics

Health centers and rural health clinics can bill G0557 and G0558. They’re paid at the non-facility Physician Fee Schedule rate, separately from and on top of the PPS encounter rate for the visit.

Two things that shrink the count

• Medicare Advantage. APCM is a traditional Medicare program. Advantage plans set their own rules, and many don’t pay these codes. Build your numbers on traditional Medicare.
• Patients already on CCM. They move from one program to the other. They don’t add on top.

Start with the per-patient number, about $645 a year at G0557 and $1,407 at G0558, and multiply it by the part of your panel that qualifies.

Frequently asked questions

What is the difference between G0557 and G0558?

Both cover Medicare patients with two or more chronic conditions. G0558 is for patients who are also Qualified Medicare Beneficiaries, and it pays $117.23 a month against $53.77 for G0557, at 2026 national rates.

Is every dual-eligible patient a G0558 patient?

No. Not every dual-eligible patient is a Qualified Medicare Beneficiary. Check QMB status, not just dual status, before assigning the code.

What counts as a chronic condition for G0557?

CMS defines it as a condition expected to last at least 12 months, or until the patient’s death, that puts the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

Do I need an initiating visit before billing G0557 or G0558?

Only for patients new to the practice. It is not needed if the practice has seen the patient in the last three years, or given them another care management service in the last year.

Can behavioral health services be billed alongside APCM?

Yes, from 2026. G0568 and G0569 cover collaborative care, and G0570 covers general behavioral health integration.

At Droxi, we built Unlock around these two tiers, to take on the operational side of APCM so a practice can run the program without adding headcount. If you want to see what your Medicare panel could support, we’re happy to run the numbers with you.