Question:
In 2026, how will we indicate practitioners are providing longitudinal or complex care who are in assisted living or receiving services in their home?
Answer:
In 2023, the codes for services performed in a patient’s home or in an assisted living facility were combined to one code set. Codes (99341—99345 for new patients) and (99347—99350 for established patients) are used for both settings. The definition of home includes a private residence, temporary lodging or short-term accommodation, including hotel, campground, hostel or cruise ship. The codes are also used for people in “assisted living facility, group home (that is not licensed as an intermediate care facility for individuals with intellectual disabilities), custodial care facility, or residential substance abuse treatment facility.”
A patient in assisted living is reported with these codes. What about patients in continuing care facilities? These are facilities that can include both individual apartments, condos, and homes and assisted living units with support. CPT® doesn’t talk about continuing care facilities, but these often include both completely independent living (home) and supportive care in assisted living. Since the same set of codes are used, does it matter?
Yes, because you still need to select the correct place of service. The place of service code for a home visit is 12. The place of service for assisted living is 13. Both are considered non-facility settings and Medicare pays claims in both settings at the non-facility rate.
Place of service codes
12 Home
13 Assisted living facility
14 Group home
16 Temporary lodging
33 Custodial care facility
55 Residential substance abuse treatment facility
(https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets)
New for 2026 is that G2211 can also be appended to your visits to Medicare beneficiaries in these places of service, in addition to outpatient clinics. Accordingly, the code was updated to include these places of service: “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to home or residence or office/outpatient evaluation and management service, new or established)) ”
Key takeaway: If the practitioner has a longitudinal relationship with a patient beiing visited at home or in assisted living, and is either the focal point for all needed health care services or is responsible for ongoing care for a single serious or complex condition, add G2211 to the claim for the E/M service. It may be added to the claim for the E/M service with a preventive medicine service, as well. It may not be reported with an E/M service and a minor procedure.
Additional Resources
Webinar – March 2024 – Home and Nursing Facility Category of Code Rules
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