Your comments tell the story
Our survey asked if you are billing G2211 and getting paid for it. And, if so, which payers are paying. The disruption of the claims processing system in the U.S., that all but halted claims submission and payment for many groups ,also hindered data collection in our survey. But combined with the data we have, your comments tells the story.
Medicare
As expected, primary care and multi-specialty practices are adding G2211 to their Medicare claims. CMS developed HCPCS code G2211, so are their MACs and Medicare Advantage plans cooperating? Not surprisingly, the MACs are doing a better job than the MA plans. 76% of primary care respondents are billing both Medicare and Medicare Advantage plans. And 84%-87% of multi-specialty groups are as well.
| % Billing Medicare | % Billing Medicare Advantage plans | |
| Primary care | 76% | 76% |
| Other* | 60% | 57% |
| Multi-specialty | 84% | 87% |
| *Other includes medical and surgical specialties, coders, and auditors. | ||
“All of the primary Medicare/MA payers we bill are paying G2211 now. However, Tricare for Life and some of the other supplements are not.”
| When billing original Medicare, are you getting paid? | When billing Medicare Advantage plans, are you getting paid? | |||
| Yes | 57% | Yes | 25% | |
| Sometimes | 12% | Sometimes | 36% | |
| Not sure | 29% | Not sure | 34% | |
| No | 2% | No | 6% | |
“We have many unprocessed UnitedHealth Care claims due to the cyberattack. The UnitedHealth Care claims that we did receive payment on were commercial.”
The question of whether your practice is getting paid when reporting G2211 is difficult to determine with much of the U.S. claims system down. It isn’t surprising that a third of respondents don’t know if they are getting paid from Medicare and Medicare Advantage. Even without that issue, some organizations purposely separate coding and reimbursement.
Medicaid
“We are a pediatric multispecialty hospital with less than 1% Medicare population. G2211 is not on our Medicaid fee schedule and we are uncertain how commercial plans will pay. We have not yet set up to code and bill G2211.”
“We are pediatric. The physicians want to report it. Waiting on leadership to make a decision. Looking into if any private payers are paying.”
Commenters in different states noted that their Medicaid plans haven’t added the code to the fee schedule and they aren’t receiving payment. This is a blow to pediatrics. The 2021 MDM guidelines made it harder for Pediatricians to report level four visits. Getting paid for longitudinal care of patients with significant chronic diseases would certainly help pediatric practices care for their patients. Pediatric groups: read on and consider billing commercial payers if you’re not doing so now.
Commercial insurers
“We are billing all insurances. As we have seen in the past, payers do retroactive approval of new CP codes. We feel receiving the denial of the new CPT is less resource intensive than to go back and code the G2211 on a payer that now says they will cover retro to 01/01/2024 or even a different date. This way the payer can do a retroactive adjudication without us having to spend over 100K recoding and reprocessing all those claims.”
“We are billing to all insurances and review the denials when they come in to see if that insurance has a policy on G2211 and if not, we ask why they are not paying. BCBS was denying and it was because of an edit they had in the system.”
“My provider rep at Aetna sent an email stating that an issue was identified with their commercial lines of business, and they will be doing a national level reprocessing of this code.”
“Most payers are paying this. Average payment YTD is $16.68.”
The answer to the question, “Are you getting paid” by individual insurers was littered with “not sure” responses. When claims processing is back to its usual state of complexity and not the current state of chaos, maybe we can answer that question.
The first response in this section tells us so much about coding for new CPT and HCPCS codes. Even though CPT codes are released in October and HCPCS codes in November, some payers don’t update their systems in time for January 1 dates of service. The strategy that the commenter recommends—bill it and let the payer do a retroactive adjudication–is sound advice, and we appreciate it. There’s no guarantee a payer will reprocess, but they typically do if the issue is that their system wasn’t ready. And, going back and finding the claims that you could have submitted months later isn’t cost effective.
The second and third comments describe two payer edits, and one payer talks about a national level re-processing. Commenters mentioned that Cigna, UMR, UHC, Humana, Tufts Health Plan and Well are have paid on the code. While the allowed amount is small, CMS predicted it will be billed on 54% of E/M claims when it is fully adopted.
“It is really dependent on if the payer recognizes the Medicare G codes.”
Just like with CPT codes, the fact that there is a code doesn’t mean you’ll get paid for it. Payers accept and pay for HCPCS codes for medications and DME (within their policies). The codes in the G section of HCPCS are for temporary or professional services. Commercial payers may or may not recognize them.
We have thoughts
“I don’t feel there is enough information out there to bill properly.”
“This code is more trouble than it is worth! I wish they would delete it.”
“Why is this code even allowed?”
Not to get too historical (or hysterical) about this, but G2211 was developed by Medicare in 2021 but the implementation was delayed by an Act of Congress (true) until 2024. It is controversial because the effect will shift payment from certain procedural specialists to primary care and medical specialties because of the budget neutrality Medicare provision. And, the MLN Matters article is –to be kind—brief. We would all like more details.
And, there is honest confusion about the rules. Someone mentioned that it doesn’t get paid with home visits. That is true. The definition itself states it can be used with office/outpatient codes. Not home visits.
The AAFP has extensive information that is free to non-members. Just about every consultant, including me, has written and/or done a video or flowchart. There are words of caution and enthusiasm. We always start with source citations, even if we wish that CMS had provided more guidance in this MLN Matters article (link above).
Thank you to everyone who participated. There were too many “not sures” about getting paid (thank you to Change Healthcare, part of Optum). But your comments tell the story.