Key facts for G0557
- Medicare payment
- $53.78
- PFS non-facility, national; facility $33.73
- Coverage code
- C
- carrier judgment, so the Medicare contractor decides coverage
- Practitioner MUE
- 1
- MAI 2
- NCCI PTP pairs
- 0
- practitioner file
- LCDs and articles
- 0 / 0
TL;DR
CMS describes HCPCS G0557, added in 2025, as "Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate: consent; ++ inform the patient of the availability of the service; that only one practitioner can furnish and be paid for the service during a calendar month; of the right to stop the services at any time (effective at the end of the calendar month); and that cost sharing may apply. ++ document in patient's medical record that consent was obtained. initiation during a qualifying visit for new patients or patients not seen within 3 years; provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week; continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; deliver care in alternative ways to traditional office visits to best meet the patient's needs, such as home visits and/or expanded hours; overall comprehensive care management; ++ systematic needs assessment (medical and psychosocial). ++ system-based approaches to ensure receipt of preventive services. ++ medication reconciliation, management and oversight of self-management. development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan; ++ care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver; coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable; ++ ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care. ++ ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated. ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record; enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary's care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/ehr referral service(s), to maintain ongoing communication with patients, as appropriate; ++ ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and e/m visits (or e-visits). analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients; be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of certified ehr technology". Under the 2026 physician fee schedule (October release) G0557 carries 0.77 work, 0.79 practice-expense and 0.05 malpractice RVUs, which at $33.4009 per RVU pays $53.78 non-facility and $33.73 facility before the locality adjustment. Qualifying APM participants get $54.04 at $33.5675. Its 2026 Q4 MUEs per date of service: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). No current LCD or billing article lists G0557; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage). HCPCS record: BETOS M5D (specialist - other); pricing indicator 13; type of service 1 (medical care). Nearby codes: G0560, G0553, G0545, G0544.
G0557 descriptor and code status
The October 2026 HCPCS Level II file describes G0557 as “Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate: consent; ++ inform the patient of the availability of the service; that only one practitioner can furnish and be paid for the service during a calendar month; of the right to stop the services at any time (effective at the end of the calendar month); and that cost sharing may apply. ++ document in patient's medical record that consent was obtained. initiation during a qualifying visit for new patients or patients not seen within 3 years; provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week; continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; deliver care in alternative ways to traditional office visits to best meet the patient's needs, such as home visits and/or expanded hours; overall comprehensive care management; ++ systematic needs assessment (medical and psychosocial). ++ system-based approaches to ensure receipt of preventive services. ++ medication reconciliation, management and oversight of self-management. development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan; ++ care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver; coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable; ++ ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care. ++ ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated. ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record; enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary's care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/ehr referral service(s), to maintain ongoing communication with patients, as appropriate; ++ ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and e/m visits (or e-visits). analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients; be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of certified ehr technology”. It sits in the G section (procedures and professional services, temporary), listed with the other G codes. Although searches often call it the "G0557 CPT code", G0557 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.
| Field | Value |
|---|---|
| Short descriptor | Adv prim care mgmt lvl 2 |
| Added to HCPCS | 2025-01-01 |
| Last action | N (no maintenance), effective 2025-01-01 |
| Coverage code | C: carrier judgment, so the Medicare contractor decides coverage |
| Pricing indicator | 13: physician fee schedule, priced by the contractor |
| BETOS category | M5D: specialist - other |
| Type of service | 1: medical care |
Medicare payment for G0557
Under the 2026 physician fee schedule (October release) G0557 carries 0.77 work, 0.79 practice-expense and 0.05 malpractice RVUs, which at $33.4009 per RVU pays $53.78 non-facility and $33.73 facility before the locality adjustment. Qualifying APM participants get $54.04 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).
| Component | Non-facility | Facility |
|---|---|---|
| Work RVU | 0.77 | 0.77 |
| Practice expense RVU | 0.79 | 0.19 |
| Malpractice RVU | 0.05 | 0.05 |
| Total RVUs | 1.61 | 1.01 |
| National payment (CF $33.4009) | $53.78 | $33.73 |
| Qualifying APM participant (CF $33.5675) | $54.04 | $33.90 |
- 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 5821 (Level 1 Health and Behavior Services), national unadjusted payment $38.28 with a minimum unadjusted copayment of $7.66.
Medically Unlikely Edits for G0557
Its 2026 Q4 MUEs per date of service: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). The practitioner MUE is a date-of-service policy edit: units above the limit deny even when split across lines, and appeals rarely succeed.
| Setting | MUE (units/DOS) | MAI | CMS rationale |
|---|---|---|---|
| Practitioner services | 1 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
| Facility outpatient hospital | 1 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
The MUE lookup for G0557 shows every setting next to any other code on the same claim.
NCCI edits and add-on rules
No active practitioner PTP pair lists G0557 in v323r0.
G0557 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 G0557 against a second code to see whether the pair bundles and whether a modifier can separate the services.
Medicare coverage policies for G0557
No current LCD or billing and coding article lists G0557. 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 G0557
the modifier reported is inconsistent with the code
the claim lacks the description, invoice or pricing detail a contractor-priced code needs
Where QuickIntell fits for G0557 claims
QuickCode supports qualified coder review of units, modifiers and NCCI pairs for G0557 before the claim leaves, and QuickRCM carries claim readiness and the denial follow-up when an edit or coverage policy is missed.
Frequently asked questions: HCPCS G0557
What does HCPCS code G0557 describe?
"Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the following elements, as appropriate: consent; ++ inform the patient of the availability of the service; that only one practitioner can furnish and be paid for the service during a calendar month; of the right to stop the services at any time (effective at the end of the calendar month); and that cost sharing may apply. ++ document in patient's medical record that consent was obtained. initiation during a qualifying visit for new patients or patients not seen within 3 years; provide 24/7 access for urgent needs to care team/practitioner, including providing patients/caregivers with a way to contact health care professionals in the practice to discuss urgent needs regardless of the time of day or day of week; continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments; deliver care in alternative ways to traditional office visits to best meet the patient's needs, such as home visits and/or expanded hours; overall comprehensive care management; ++ systematic needs assessment (medical and psychosocial). ++ system-based approaches to ensure receipt of preventive services. ++ medication reconciliation, management and oversight of self-management. development, implementation, revision, and maintenance of an electronic patient-centered comprehensive care plan; ++ care plan is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver; coordination of care transitions between and among health care providers and settings, including referrals to other clinicians and follow-up after an emergency department visit and discharges from hospitals, skilled nursing facilities or other health care facilities as applicable; ++ ensure timely exchange of electronic health information with other practitioners and providers to support continuity of care. ++ ensure timely follow-up communication (direct contact, telephone, electronic) with the patient and/or caregiver after an emergency department visit and discharges from hospitals, skilled nursing facilities, or other health care facilities, within 7 calendar days of discharge, as clinically indicated. ongoing communication and coordinating receipt of needed services from practitioners, home- and community-based service providers, community-based social service providers, hospitals, and skilled nursing facilities (or other health care facilities), and document communication regarding the patient's psychosocial strengths and needs, functional deficits, goals, preferences, and desired outcomes, including cultural and linguistic factors, in the patient's medical record; enhanced opportunities for the beneficiary and any caregiver to communicate with the care team/practitioner regarding the beneficiary's care through the use of asynchronous non-face-to-face consultation methods other than telephone, such as secure messaging, email, internet, or patient portal, and other communication-technology based services, including remote evaluation of pre-recorded patient information and interprofessional telephone/internet/ehr referral service(s), to maintain ongoing communication with patients, as appropriate; ++ ensure access to patient-initiated digital communications that require a clinical decision, such as virtual check-ins and digital online assessment and management and e/m visits (or e-visits). analyze patient population data to identify gaps in care and offer additional interventions, as appropriate; risk stratify the practice population based on defined diagnoses, claims, or other electronic data to identify and target services to patients; be assessed through performance measurement of primary care quality, total cost of care, and meaningful use of certified ehr technology" (short descriptor "Adv prim care mgmt lvl 2"), in the G section (procedures and professional services, temporary). Added 2025-01-01.
Is G0557 a CPT code?
No. G0557 is a CMS HCPCS Level II code; CPT codes are the AMA's five-character set. Searches for "G0557 CPT code" mean this Level II code.
What does Medicare pay for G0557?
Under the 2026 physician fee schedule (October release) G0557 carries 0.77 work, 0.79 practice-expense and 0.05 malpractice RVUs, which at $33.4009 per RVU pays $53.78 non-facility and $33.73 facility before the locality adjustment. Qualifying APM participants get $54.04 at $33.5675.
How many units of G0557 can be billed per day?
Its 2026 Q4 MUEs per date of service: practitioner 1 (MAI 2, Code Descriptor / CPT Instruction); hospital outpatient 1 (MAI 2, Code Descriptor / CPT Instruction). 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 G0557?
No current LCD or billing article lists G0557; its HCPCS coverage code is C (carrier judgment, so the Medicare contractor decides coverage).
CMS guidance
Medicare Learning Network publications that CMS issues on this topic, cited by ICN and publication date:
- Behavioral Health Integration Services(MLN909432, )Behavioral health integration and collaborative care: team members, consent and the billing codes.
- Chronic Care Management Services(MLN909188, )Chronic care management eligibility, consent, the care plan and the monthly billing rules.
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.
- HCPCS Level II alpha-numeric file, October 2026Version October 2026 · effective 2026-10-01 · file HCPC2026_OCT_ANWEB_09232026.txtSHA-256 c25240c63108756d…
- Medicare PFS national relative value file RVU26D (non-QPP), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_nonQPP.csvSHA-256 4d0d3f19bd954ffc…
- Medicare PFS national relative value file RVU26D (qualifying APM participants), October 2026Version RVU26D, released 2026-08-26 · effective 2026-10-01 · file PPRRVU2026_Oct_QPP.csvSHA-256 59d3734704853936…
- OPPS Addendum B, October 2026Version October 2026 · effective 2026-10-01 · file 508-compliant-version-2026_October_Web_Addendum_B.09.28.26.csvSHA-256 6ad7393a318bf1b9…
- Integrated Outpatient Code Editor v27.3 data tables: status and payment indicatorsVersion I/OCE v27.3 (October 2026) · effective 2026-10-01 · file Data_Status_Indicator.txtSHA-256 78f119ef0a435351…
- NCCI MUE table, practitioner services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_PractitionerServices_Eff_10-01-2026.csvSHA-256 ef038efaf902b7bd…
- NCCI MUE table, facility services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_OutpatientHospitalServices_Eff_10-01-2026.csvSHA-256 3af9f4e99cc587e2…
- NCCI MUE table, dme services, effective 2026-10-01Version 2026 Q4 · effective 2026-10-01 · file MCR_MUE_DMESupplierServices_Eff_10-01-2026.csvSHA-256 6fa4fbba852f7b74…
- NCCI PTP edits, practitioner, v323r0 (four files)Version v323r0 (2026 Q4) · effective 2026-10-01 · file ccipra-v323r0-f1.TXTSHA-256 7793c0b6686c1e22…
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.