Reimbursement
$107.07
Threshold
N/A
2026 Status
Active
What is CPT Code G0558?
CPT G0558 is defined as: Advanced Primary Care Management (APCM) services, Level 3. This high-intensity bundle covers longitudinal care management for Qualified Medicare Beneficiaries (QMB) or other dual-eligible patients with two or more chronic conditions. It includes all the requirements of Level 2, plus targeted coordination addressing social determinants of health (SDOH), health equity, and navigation of complex benefit structures.
This code is primarily used for ACPM services. It falls under the category of Care Management / APCM and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
Physician Effort
PE (Non-Fac)
Practice Expense
Malpractice
Risk Factor
Total RVU
Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor
2026 CMS Policy Intelligence
efficiency shield
Strategically exempt from the -2.5% efficiency adjustment. CMS has prioritized Level 3 APCM to ensure that practices serving the most vulnerable populations are not penalized by productivity-based work cuts.
equity incentive
G0558 is a flagship 2026 policy designed to financially reward primary care providers who manage the 'total cost of care' for dual-eligible beneficiaries through intensive management.
conversion factor
Utilizes the 2026 Non-QP rate of $33.40.
Administrative Framework
Operational Requirements
eligibility threshold
Patient must be a Qualified Medicare Beneficiary (QMB) or dual-eligible for Medicare and Medicaid.
condition threshold
Patient must have two or more chronic conditions expected to last 12+ months or until death.
sdoh integration
Practices must perform social determinants of health (SDOH) screenings and document the navigation of identified barriers (e.g., housing, transportation, food security).
frequency
Billed once per calendar month.
Compliance Checklist
Audit Defense
No specific audit defense elements defined.
2026 Update
NEW 2026 CODE. Represents the highest level of monthly primary care management reimbursement for the most complex patients.
Common Clinical Scenarios
No clinical examples provided.
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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