Primary Care Billing Quick Reference, 2026

Use: Add-on for an office E/M when the visit is part of an ongoing care relationship or management of a serious/complex condition. "Focal point" means you coordinate or manage most needed care for that patient or condition.

Stacks: Office E/M 99202-99215. If the E/M has modifier 25, Medicare pays G2211 only when the same-day other service is an AWV, vaccine administration, or Medicare Part B preventive service.

Minimum: Medical necessity for the E/M plus a sentence naming your longitudinal role. Example: "I manage this patient's ongoing diabetes care." No separate time threshold.

Use: Medicare prolonged office time.

Stacks: Only when selecting 99205, 99215, or 99483 by time.

Minimum: Total same-day physician/QHP time. Thresholds: 99205 at 89+ min, 99215 at 69+ min, 99483 at 100+ min. Do not bill unless the full 15-minute prolonged-service threshold is met.

Use: Welcome to Medicare/IPPE, once during the first 12 months of Medicare Part B.

Stacks: Problem E/M-25 only if there is a significant, separately identifiable problem service. ACP may be performed during the IPPE if voluntary discussion, time, and participants are documented.

Minimum: Required IPPE elements: medical/social history, risk factors, measurements, vision, depression/safety/function review, education/counseling, and written plan.

Use: First Medicare AWV.

Stacks: Problem E/M-25, ACP-33, and G0136-33 when each code has separate required documentation. G2211 may attach to the E/M when the visit shows an ongoing care relationship or serious/complex condition plus the longitudinal role sentence described in the G2211 row.

Minimum: HRA, current providers/suppliers, history, measurements, cognitive screen, depression/function/safety review, risk-factor list, written 5- to 10-year screening schedule, and personalized prevention plan.

Use: Subsequent Medicare AWV, at least 12 months after the prior covered AWV unless the payer uses a different frequency rule.

Stacks: Same as G0438. Do not bill within 12 months of G0402 or G0438.

Minimum: Update HRA, history, current providers/suppliers, measurements, cognitive screen, risk-factor list, screening schedule, and prevention plan.

Use: Commercial preventive physicals by age: 99381-99387 for new patients and 99391-99397 for established patients. Medicare does not pay these codes for routine physicals.

Stacks: Problem E/M-25 only if medically necessary problem work is separate from routine prevention.

Minimum: Age-, anatomy-, and risk-appropriate preventive history, exam, screening counseling, immunizations/orders, and, when billing problem E/M, separate problem-oriented HPI/exam elements, assessment, and plan.

Use: ACP. Use 99497 for 16-30 min; 99498 for each additional 30 min.

Stacks: AWV with modifier 33 for waived cost share once per year. Outside an AWV, normal cost share may apply.

Minimum: Voluntary face-to-face discussion, total time, participants, who would make decisions if the patient lacked capacity, goals/preferences, and forms completed or reviewed if any. Forms are not required unless policy requires them.

Use: Social determinants of health risk assessment, including physical activity and nutrition risk, 5-15 min.

Stacks: AWV with modifier 33 once per year for waived cost share; E/M or behavioral health visit up to every 6 months with cost share.

Minimum: Name the standardized evidence-based tool or questionnaire, total time, result, and counseling/referral/plan.

Use: Annual alcohol misuse screen or depression screen.

Stacks: Follow Part B preventive service rules. Do not separately bill the same screening element when it is bundled into another specific wellness service.

Minimum: Validated screen name, score/result, positive/negative interpretation using that tool's cutoff, and follow-up plan/referral if positive.

Use: Tobacco cessation counseling: 99406 for 3-10 min; 99407 for greater than 10 min.

Stacks: Can pair with E/M when counseling content and time are separate from E/M time. Do not count the same minutes twice.

Minimum: Tobacco status, counseling content, readiness/plan, medication/referral if used, and exact counseling time.

Use: Cognitive assessment and written care plan for cognitive impairment.

Stacks: Prefer a separate visit. Same-day billing with AWV needs distinct history/evaluation, care-plan work, MDM/time, and documentation. Do not stack with office E/M or ACP on the same date.

Minimum: Independent historian, cognition-focused evaluation, moderate/high MDM documented by problem/data/risk, function/capacity, named staging tool such as FAST or CDR, medication reconciliation, behavioral/safety/caregiver assessment, advance care plan, and written care plan provided to patient/caregiver or sent to relevant clinicians.

Use: TCM after discharge from inpatient hospital, psychiatric hospital, long-term care hospital, SNF, inpatient rehab, observation, hospital partial hospitalization, or community mental health center partial hospitalization to a community setting such as home or assisted living.

Stacks: Do not separately bill the included face-to-face office visit. Other services need their own medical necessity and cannot duplicate TCM work or time.

Minimum: Discharge date and setting, community return, contact within 2 business days or documented attempts, medication reconciliation by the visit, non-face-to-face coordination such as records review/referrals/resources, and face-to-face visit within 14 days with moderate MDM for 99495 or within 7 days with high MDM for 99496.

Use: APCM monthly bundle. G0557 requires 2+ chronic conditions. G0558 requires QMB status plus 2+ chronic conditions.

Stacks: Once per patient per month. Do not bill another care-management code for the same patient/month when service elements overlap or the payer bundles them.

Minimum: Consent; practice/clinician responsible for ongoing primary care coordination; prior initiating visit date or payer rule that does not require one; 24/7 patient access to a care team member or urgent clinical advice pathway; care plan; transition coordination; systematic risk stratification, outreach, gap closure, or registry management; and practice capacity for required performance reporting.