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HCPCS G0538 · Level II · G code

G0538: Atherosclerotic cardiovascular disease (ascvd) risk management services, HCPCS Level II G code

Compiled from CMS files by the QuickIntell RCM Editorial Team · Data effective · Method: reference methodology · Report a data correction

Data currency: HCPCS Level II file: October 2026 (effective October 1, 2026); PFS relative value file: RVU26D, released August 26, 2026 (effective October 1, 2026); NCCI MUE tables: 2026 Q4 (effective October 1, 2026); NCCI PTP edits: v323r0 (2026 Q4) (effective October 1, 2026); OPPS Addendum B: October 2026 (effective October 1, 2026). Next CMS release: January 1, 2027 (quarterly update) for the HCPCS Level II file and NCCI MUE tables and NCCI PTP edits and OPPS Addendum B; RVU27A with the CY2027 PFS final rule, effective January 1, 2027 for the PFS relative value file.

Key facts for G0538

Medicare payment
$17.03
PFS non-facility, national; facility $8.02
Coverage code
C
carrier judgment, so the Medicare contractor decides coverage
Practitioner MUE
1
MAI 2
OPPS status
SI S
Procedure or service, not discounted when multiple
NCCI PTP pairs
0
practitioner file
LCDs and articles
0 / 0

TL;DR

CMS describes HCPCS G0538, added in 2025, as "Atherosclerotic cardiovascular disease (ascvd) risk management services; clinical staff time; per calendar month". National PFS payment for G0538 is $17.03 in an office and $8.02 in a facility (October 2026), built from 0.18 work, 0.32 practice-expense and 0.01 malpractice RVUs at $33.4009 per RVU. Qualifying APM participants get $17.12 at $33.5675. CMS caps G0538 at practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction) units per day in the 2026 Q4 MUE tables. G0538 appears in no active LCD or billing and coding article, so coverage follows HCPCS coverage code C (carrier judgment, so the Medicare contractor decides coverage) and any NCD. HCPCS record: BETOS M5D (specialist - other); pricing indicator 13; type of service 1 (medical care). Nearby codes: G0537, G0539, G0541, G0542.

G0538 descriptor and code status

The October 2026 HCPCS Level II file describes G0538 as “Atherosclerotic cardiovascular disease (ascvd) risk management services; clinical staff time; per calendar month”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes. Although searches often call it the "G0538 CPT code", G0538 is a HCPCS Level II code maintained by CMS, not an AMA CPT code; both go in the same procedure-code field on the claim.

HCPCS file attributes of G0538
FieldValue
Short descriptorAscvd rsk mng clin stf pr mo
Added to HCPCS2025-01-01
Last actionN (no maintenance), effective 2025-01-01
Coverage codeC: carrier judgment, so the Medicare contractor decides coverage
Pricing indicator13: physician fee schedule, priced by the contractor
BETOS categoryM5D: specialist - other
Type of service1: medical care

Medicare payment for G0538

National PFS payment for G0538 is $17.03 in an office and $8.02 in a facility (October 2026), built from 0.18 work, 0.32 practice-expense and 0.01 malpractice RVUs at $33.4009 per RVU. Qualifying APM participants get $17.12 at $33.5675. The amounts below are national figures from the October 2026 CMS files; the contractor applies the locality, rural or state adjustment and the beneficiary's cost sharing.

Physician fee schedule (RVU26D)

Status A: active: paid separately under the physician fee schedule when covered. Global period XXX (global surgery concept does not apply); PC/TC indicator 0 (physician service; the professional/technical split does not apply).

PFS relative values and national payment for G0538
ComponentNon-facilityFacility
Work RVU0.180.18
Practice expense RVU0.320.05
Malpractice RVU0.010.01
Total RVUs0.510.24
National payment (CF $33.4009)$17.03$8.02
Qualifying APM participant (CF $33.5675)$17.12$8.06
  • Multiple procedures (modifier 51): no multiple-procedure reduction
  • Bilateral (modifier 50): 150% bilateral adjustment does not apply
  • Assistant at surgery: assistant at surgery paid only with documentation; co-surgeons: co-surgeons not permitted; team surgery: team surgeons not permitted
  • Physician supervision of diagnostic procedures: supervision concept does not apply

Hospital outpatient (OPPS Addendum B)

Status indicator S (Procedure or service, not discounted when multiple), APC 5822 (Level 2 Health and Behavior Services), national unadjusted payment $103.79 with a minimum unadjusted copayment of $20.76.

Medically Unlikely Edits for G0538

CMS caps G0538 at practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction) units per day in the 2026 Q4 MUE tables. The practitioner MUE is a date-of-service policy edit: units above the limit deny even when split across lines, and appeals rarely succeed.

MUE values for G0538 by setting
SettingMUE (units/DOS)MAICMS rationale
Practitioner services12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction
Facility outpatient hospital12 Date of Service Edit: PolicyCode Descriptor / CPT Instruction

The MUE lookup for G0538 shows every setting next to any other code on the same claim.

NCCI edits and add-on rules

No active practitioner PTP pair lists G0538 in v323r0.

G0538 is neither an add-on code nor a designated primary code in the 2026 Q4 NCCI add-on edit file.

Pair counts show exposure, not the answer for one claim. Check G0538 against a second code to see whether the pair bundles and whether a modifier can separate the services.

Medicare coverage policies for G0538

No current LCD or billing and coding article lists G0538. The HCPCS coverage code C means carrier judgment, so the Medicare contractor decides coverage, and any National Coverage Determination for the service still applies.

Denials to expect on G0538

CARC 50 · N115

the service is not reasonable and necessary for the diagnosis on the claim

CARC 151 · N362

units of G0538 exceed the practitioner MUE of 1 per date of service

CARC 4

the modifier reported is inconsistent with the code

CARC 16

the claim lacks the description, invoice or pricing detail a contractor-priced code needs

Where QuickIntell fits for G0538 claims

QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0538 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.

See QuickCode for coder reviewSee QuickRCM for denial follow-upBook a meeting

Frequently asked questions: HCPCS G0538

What does HCPCS code G0538 describe?

"Atherosclerotic cardiovascular disease (ascvd) risk management services; clinical staff time; per calendar month" (short descriptor "Ascvd rsk mng clin stf pr mo"), in the G section (procedures and professional services, temporary). Added 2025-01-01.

Is G0538 a CPT code?

It is not. G0538 belongs to the G section (procedures and professional services, temporary) of HCPCS Level II, the CMS code set, not to AMA CPT. "G0538 CPT code" searches refer to it.

What does Medicare pay for G0538?

National PFS payment for G0538 is $17.03 in an office and $8.02 in a facility (October 2026), built from 0.18 work, 0.32 practice-expense and 0.01 malpractice RVUs at $33.4009 per RVU. Qualifying APM participants get $17.12 at $33.5675.

How many units of G0538 can be billed per day?

CMS caps G0538 at practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction) units per day in the 2026 Q4 MUE tables. For the practitioner MUE (MAI 2), units above 1 deny for the whole day as a policy limit; denials arrive as CARC 151.

Does Medicare cover G0538?

G0538 appears in no active LCD or billing and coding article, so coverage follows HCPCS coverage code C (carrier judgment, so the Medicare contractor decides coverage) and any NCD.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.

Disclaimer

This page is an operational reference compiled from CMS publications: the HCPCS Level II file, the physician, DMEPOS and clinical laboratory fee schedules, OPPS and ASC addenda, NCCI MUE, PTP and add-on edit tables and the Medicare Coverage Database. Amounts are Medicare national figures before locality and state adjustment; Medicaid and commercial payers set their own. CPT codes are shown as numbers only; CPT descriptors are copyright AMA. Nothing here is legal, clinical or billing advice.

Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.