Check Each Program Fact Card Against Current CMS Rules

Program Fact Cards

Companion to Getting Paid to Do the Right Thing · Updated 2026-09-29

These are the fact cards “Medicare Pays for More Than a Dozen Programs Most Practices Don’t Bill” works from, one per program, in the order that chapter takes them. Each card answers three of the chapter’s five questions: what the program pays for, who qualifies, and what has to happen. The chapter answers the other two, what trips practices up and what the program can’t be combined with, and its Table 3.1 holds every combination rule in one place.

Every card states CMS’s rules as of its 2025 and 2026 guidance. Every dollar amount is as of 2026, national, non-facility, and approximate, calculated from CMS’s 2026 relative value file and conversion factor; your payment will differ by locality, with sequestration, and under any Medicare Advantage contract. These are the parts of the book that go out of date first. Check each card against the current CMS booklet and fee schedule before you plan on it. When a card no longer matches the rules, the card is out of date; the chapter’s reasoning about the program usually still holds.

Chronic care management

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Non-face-to-face management of two or more chronic conditions expected to last at least 12 months or until death, which put the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.
Who can bill	Physicians (MD, DO), nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives.
What has to happen	An initiating visit (an E/M visit, AWV, or initial preventive physical exam) for new patients or patients not seen within a year. Written or verbal consent that tells the patient about cost sharing, that only one practitioner can bill CCM each month, and that they can stop at any time. A certified EHR, an electronic care plan, 24/7 access, and continuity with a designated care-team member. The required minutes of qualifying work in the calendar month.
Who does the work	Clinical staff under the billing practitioner’s general supervision for the staff-time codes; the practitioner personally for the practitioner-time codes.
Cost sharing	Yes. Some patients have Medigap coverage that pays it.
Main codes and amounts	99490, clinical staff, first 20 minutes: $66.13. +99439, each additional 20 minutes: $50.44. 99491, practitioner personally, first 30 minutes: $89.18. +99437, each additional 30 minutes: $63.13. 99487, complex CCM, first 60 minutes with moderate or high complexity decision-making: $144.29. +99489, each additional 30 minutes: $78.16.

Principal care management

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Management of one high-risk condition expected to last at least 3 months that places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death.
What has to happen	Monthly service when the patient needs it; a new initiating visit after one year. At least 30 minutes in the calendar month; nothing is billable below that.
Main codes and amounts	99424, practitioner, first 30 minutes: $87.51. +99425, additional time: $61.46. 99426, clinical staff, first 30 minutes: $67.80. +99427, additional time: $54.11.

Advanced primary care management

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	A monthly bundle of primary care capabilities that incorporates elements of CCM, PCM, TCM, interprofessional consultations, and e-visits. Billed once per patient per calendar month, with no minutes to count.
Who qualifies	Three levels. Level 1: patients with zero or one chronic condition. Level 2: two or more chronic conditions. Level 3: two or more chronic conditions and Qualified Medicare Beneficiary status.
What has to happen	The practice must be able to furnish 13 service elements, which must be available but don’t all have to be delivered every month. They include documented consent (telling the patient only one practitioner can bill per month and they can stop any time); an initiating visit for new patients (not seen within 3 years); 24/7 access with real-time access to the record; continuity with a designated care-team member; alternative ways to get care, such as expanded hours or home visits; comprehensive care management; an electronic care plan shared with the patient; transition follow-up, including contact within 7 days of an emergency, hospital, or skilled nursing facility discharge; enhanced communication, such as secure messaging and virtual check-ins; and population data analysis and risk stratification.
Performance measurement	The practice reports the Value in Primary Care MIPS Value Pathway (reporting starts in 2026 for the 2025 performance year) or participates in the Shared Savings Program, ACO REACH, Making Care Primary, or Primary Care First.
Cost sharing	Yes.
Main codes and amounts	G0556, Level 1: $16.37. G0557, Level 2: $53.78. G0558, Level 3: $117.24. Behavioral health add-ons for APCM patients, billed by the same practitioner in the same month: G0568 and G0569 (Collaborative Care, initial and subsequent): $161.66 and $145.96; G0570 (general BHI): $57.78.
Attestation	Billing APCM counts as attesting that the practice has the required capabilities in place.

Transitional care management

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	A 30-day period starting on the day of discharge from an inpatient or partial hospitalization setting (a hospital, skilled nursing facility, rehabilitation facility, and others) back to the community.
What has to happen	Contact with the patient or caregiver, directly, by phone, or electronically, within 2 business days of discharge. Medication reconciliation on or before the face-to-face visit. A face-to-face visit within 14 days (moderate complexity) or 7 days (high complexity). The visit isn’t billed separately and can be done by telehealth.
Who does the work	The non-face-to-face work can be done by clinical staff or auxiliary personnel under general supervision.
Main codes and amounts	99495, moderate complexity, visit within 14 days: $220.11. 99496, high complexity, visit within 7 days: $298.60.

Remote physiologic monitoring

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Monitoring of a chronic or acute condition through physiologic data, such as blood pressure, weight, glucose, or oxygen saturation, in three parts: education and device setup, device supply, and treatment management.
Who qualifies	A patient with a chronic or acute condition and an established relationship with the practice. Only practitioners eligible to bill E/M services can bill it.
What has to happen	The device must meet the FDA’s definition of a medical device and upload data automatically. It must collect and transmit data on at least 2 days in every 30. Patient consent at the time the service is provided. Only one practitioner can bill remote monitoring for a patient in a 30-day period.
Who does the work	Auxiliary personnel under general supervision.
Main codes and amounts	99453, setup and education: $21.71. 99454, device supply, 16–30 days of data: $52.11. 99445, device supply, 2–15 days of data (new for 2026): $52.11. 99457, treatment management, first 20 minutes: $51.77. +99458, each additional 20 minutes: $41.42. 99470, treatment management, first 10 minutes (new for 2026): $26.05. 99091, physician collection and interpretation, 30 minutes: $55.45.

Remote therapeutic monitoring

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Monitoring of non-physiologic data, which can be self-reported: musculoskeletal and respiratory status, adherence, and response to treatment.
What has to happen	Data on at least 2 days in 30, with codes for 2–15 days and 16–30 days. No established-patient requirement.
Main codes and amounts	98975, setup: $21.71. 98976, respiratory device, 16–30 days: $52.11. 98977, musculoskeletal device, 16–30 days: $51.44. 98984 and 98985, respiratory and musculoskeletal, 2–15 days (new for 2026): $52.11 and $51.44. 98979, treatment management, first 10 minutes (new for 2026): $26.39. 98980, first 20 minutes: $54.11. +98981: $41.42. Cognitive behavioral therapy device codes are priced by the Medicare contractor.

Behavioral health integration and Collaborative Care

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	General BHI: monthly care management for a behavioral health condition, including validated rating scales, care planning, coordination, and continuity. CoCM: a team of the treating practitioner, a behavioral health care manager, and a psychiatric consultant, with a weekly caseload review.
What has to happen	General BHI: at least 20 minutes of clinical staff time in the month. CoCM: 70 minutes in the first month and 60 in later months. Verbal consent is allowed, and the patient must be told that cost sharing applies.
Who does the work	Clinical staff under general supervision. A version of general BHI (G0323) covers the same service delivered by a clinical psychologist or clinical social worker.
Main codes and amounts	99484, general BHI: $57.45. 99492, CoCM first month: $160.32. 99493, CoCM later months: $144.96. +99494, each additional 30 minutes: $61.46. For APCM patients, the practice bills the APCM behavioral health add-ons in Table 3.3 instead, which aren’t time-based.

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Navigation for one serious, high-risk condition expected to last at least 3 months, such as cancer, dementia, heart failure, or a serious mental illness, after an initiating E/M visit.
Who does the work	Trained or certified auxiliary personnel, incident to the billing practitioner and under general supervision. They may be contracted, including through community-based organizations. A peer-support version is designed for peer support specialists.
What has to happen	An initiating visit by the practitioner who will bill PIN. Consent. At most once per practitioner per month for a given condition.
Cost sharing	Yes, Part B cost sharing applies.
Main codes and amounts	G0023, first 60 minutes: $87.18. +G0024, each additional 30 minutes: $54.44. G0140, peer support, first 60 minutes: $89.18. +G0146: $53.44.

Community health integration

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Work to address unmet health-related social needs that significantly limit diagnosis or treatment.
Who does the work	Community health workers or community-based organization staff, under general supervision.
What has to happen	An initiating E/M visit or AWV. Advance consent, written or verbal and documented, telling the patient that cost sharing applies and only one practitioner can bill each month.
Main codes and amounts	G0019, first 60 minutes: $86.17. +G0022, each additional 30 minutes: $54.11.

Caregiver training services

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	Training for a patient’s unpaid caregiver, defined broadly as a family member, friend, or neighbor who gives unpaid help to a person with a chronic illness or disabling condition, so they can help carry out the treatment plan. Separate codes cover behavior management training.
What has to happen	The patient’s consent, documented in the record. Multiple caregivers of the same patient trained together are billed once.
Cost sharing	Yes, Part B cost sharing applies.
Main codes and amounts	97550, individual, first 30 minutes: $52.77. +97551: $26.05. 97552, group: $22.04. 96202, behavior management, group, first 60 minutes: $20.04. +96203: $5.34. Added in 2025: G0541, without the patient present, first 30 minutes: $53.11. +G0542: $26.05. G0543, group: $22.04. G0539 and G0540 cover behavior management training for one patient’s caregivers.

Chronic pain management

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What it buys	A monthly bundle of diagnosis, assessment and monitoring, a validated pain rating scale, a person-centered care plan, medication management, pain and health literacy counseling, crisis care, and coordination.
What has to happen	An initial face-to-face visit of at least 30 minutes.
Main codes and amounts	G3002, first 30 minutes: $86.17. +G3003, each additional 15 minutes: $31.73.

Annual wellness visit and advance care planning

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Question	As of 2026
What the AWV buys	A health risk assessment and a personalized prevention plan, including history, vital signs, cognitive assessment, depression risk review, functional assessment, a screening schedule, and advice. Medicare’s beneficiary site says plainly that it isn’t a routine physical exam.
Who qualifies for the AWV	Patients past their first 12 months of Part B who haven’t had an initial preventive physical exam or AWV in the past 12 months.
AWV cost sharing	None when the clinician accepts assignment, though other services during the visit may carry coinsurance.
What ACP buys	A voluntary, face-to-face conversation about advance directives. Time-based; 15 minutes or less isn’t billable. No frequency limit, but a repeat needs a documented change in the patient’s condition or wishes.
ACP cost sharing	Waived when ACP is done on the same day as the AWV, by the same clinician, on the same claim with the right modifier. If the AWV is denied, cost sharing applies.
Main codes and amounts	G0438, initial AWV: $174.35. G0439, subsequent AWV: $137.61. 99497, ACP first 30 minutes (billable at 16 minutes or more): $86.84. +99498: $78.16.

Smaller services worth knowing

As of 2026; amounts national, non-facility, approximate; check the current fee schedule.

Service	As of 2026
Physical activity and nutrition risk assessment (G0136)	Formerly the social determinants of health risk assessment; the 2026 rule kept the code and refocused it. A 5–15 minute standardized assessment, not for routine screening, billed with an E/M visit, TCM, certain behavioral health visits, or the AWV. Once every 6 months per practitioner per patient. Cost sharing applies except when it’s part of the AWV. $20.04.
Brief communication and virtual check-ins	98016, brief communication technology-based service (it replaced G2012): $17.37. G2010, remote evaluation of an image the patient sends: $13.03. G2252, longer check-in, 11–20 minutes: $28.39.
E-visits	Online digital E/M through the portal, 99421–99423: $15.70–$48.77.
Interprofessional consultations	Clinician-to-clinician consults, 99446–99449 and 99451–99452: $19.04–$76.15.
Digital mental health treatment	G0552, device supply and onboarding: priced by the Medicare contractor. G0553, first 20 minutes of monthly management: $54.11. G0554, each additional 20 minutes: $41.42.