Part of Advanced Primary Care Management
HCPCS G0558: Advanced Primary Care Management, Level 3
Flat monthly APCM service for a patient with two or more chronic conditions who is also a Qualified Medicare Beneficiary (QMB).
Time threshold & code combinations
No minimum time requirement: billed once per calendar month per patient.
- Mutually exclusive with G0556 and G0557 for the same month
- Not billed alongside CCM, PCM, or TCM for the same patient and period
Who can bill
- Physicians
- Nurse practitioners, physician assistants, and other non-physician practitioners serving as the patient's continuing primary care focal point
Eligibility & billing requirements
- Meets the same two-or-more qualifying chronic condition criteria as Level 2
- Patient is enrolled as a Qualified Medicare Beneficiary (QMB) specifically, being enrolled in a different Medicare Savings Program category (such as SLMB or QI) does not qualify
- Documented patient consent
- All APCM service elements must be in place for the month billed
- Only one APCM tier billed per patient per calendar month
- Not billed concurrently with CCM, PCM, or TCM for the same patient and period
When to use it
Dual-eligible patient with multiple conditions
A patient with COPD and heart failure has confirmed QMB status through the state Medicaid eligibility file.
Billing: G0558
QMB status confirmed after enrollment
A patient already billed under G0557 is later confirmed as QMB; the practice updates its records and bills Level 3 going forward once status is confirmed.
Billing: G0558, starting the month QMB status is confirmed
Documentation checklist
- Consent on file
- Care plan reflecting the qualifying chronic conditions
- Confirmation of QMB status specifically (not another Medicare Savings Program category like SLMB or QI) in the record
Common billing mistakes
- Billing G0558 without confirmed, documented QMB status
- Not periodically re-checking QMB status, since eligibility can change