Congress delayed implementation of code G2211 for three years. CMS is proposing to begin paying for it Jan. 1, 2024.  

This information is from the 2024 Proposed Rule and is not final. Let’s start with the basics. 

• G2211 (definition below) is an add-on code to office and other outpatient services, 99202–99215.
• CMS believes it will be used by primary care and other specialties who treat a single, serious condition or a complex condition with a consistency and continuity over a long period of time.
• For 2024, CMS is proposing that it may not be reported when modifier 25 is used on the E/M service on a day of a minor procedure.

G2211 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 office/outpatient evaluation and management visit, new or established)

This code is for practitioners who use E/M services to report most of their services. CMS believes that the valuations for office visit codes don’t adequately reflect the cost of caring for the complexity of certain kinds of visits. CMS believes that the values don’t account “for the resource costs associated with primary care and other longitudinal care of complex patients.” p. 296, Proposed Rule.

The goal of developing and paying for this service is to pay clinicians to address needs with consistency and continuity over long periods of time. The payment is for the time, intensity and practice expense of providing these services to patients.

Not all visits

CMS is proposing not to pay for the add-on code when used with modifier 25, on the date of a minor procedure.

CMS also states that not all visits in primary care would be eligible. A patient who is seen for an acute health need might not require extra work at that visit for coordination or follow up. They provide specific examples of conditions that would not require the add on complexity code: seasonal allergies, new onset GERD, treatment for a fracture, and “where comorbidities are either not present or not addressed, and/or when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for ongoing medical care for that particular patient with consistency and continuity over time.” p 301 Proposed Rule.

Clinician’s relationship with the patient, type of problem

Notice the word: continuity, consistency over time, longitudinal care.

CMS expected frequency

Some specialty societies are against implementing G2211 because of the budget neutrality rule. New services added to the Medicare Fee Schedule cause an adjustment to all other services to keep the total Part B expenditure budget neutral. Adding the cost of G2211 will decrease fees for other services.

CMS expects that G2211 will be billed with 38% of all E/M services initially and 54% of all E/M services when fully adopted. This doesn’t mean every physician or NPP will use the code 38% of the time next year. Some specialties will use the code more frequently (primary care) and some less frequently.

Q&A from August 17, 2023 CMS Proposed Rule Webinar

The section of the CMS 2024 Proposed Rule that describes G2211 is brief. 7 pages. We’ve posted it here so you can read it for yourself.

Question: Who will decide which condition is serious? What would be a criteria for it?

• Answer: CMS doesn’t define descriptions that are serious, but they do give a few examples of when not to use it.

CMS says not to use G2211 in these examples:

Furthermore, in contrast to situations, where the patient’s overall, ongoing care is being managed, monitored, and/or observed by a specialist for a particular disease condition, we continue to believe that there are many visits with new or established patients where the O/O E/M visit complexity add-on code would not be appropriately reported, such as when the care furnished during the O/O E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature; such as, but not limited to, a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed, and/or when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time (85 FR 84570 and 84571).

Question: What if two providers of different specialties bill this code on the same date of service.

• Answer: CMS doesn’t address this in their document. My thought is that both would be paid, if the base E/M codes were paid. (different specialties)

Question: Would you be able to assign the E/M office code, the G2211 and the G2212/99417?

•  Answer:  There is nothing in this section of the CMS proposed rule that describing G2211 that mentions prolonged care, or says that you may or may not be able to bill them the same.

Question: How are “other specialties” that wouldn’t be eligible defined?

•  Answer:  The Proposed Rule doesn’t name names. I mean, doesn’t name specialties. Read these quotes to see what CMS is thinking.

Specialties

Specifically, we took into account the likelihood that primary care specialties will have a higher utilization of the add- on code than other specialties, surgical specialties will have the lowest utilization since they are less likely to establish longitudinal care relationships with patients, and other specialists are more likely to have longitudinal care relationships than surgical specialties but less likely than primary care specialists.

CMS’s thoughts when they proposed the code in 2021

We also estimated that the O/O E/M visit complexity add-on service would be reported by specialties that rely on office/outpatient E/M visits to report the majority of their services and would be billed in addition to those E/M visits.

We reiterated our belief that the O/O E/M visit complexity add-on reflects the time, intensity, and PE resources involved when practitioners furnish the kinds of O/O E/M office visit services that enable them to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single high-risk disease) and to address the majority of patients’ health care needs with consistency and continuity over longer periods of time. In response to comments, we also made further refinements to the HCPCS code descriptor to clarify that the code applies to a serious condition rather than any single condition.

Question: G2211 Are there specific documentation requirements needed from the provider to  utilize?

• Answer:  None are mentioned in the Proposed Rule. I would think CMS would be looking at claims data to see if the patient has a longitudinal relationship with the patient. I assume they’ll have some diagnosis coding edits, but who knows what those will be. The following quote seems to indicate that acute diagnoses might not show the medical necessity for G2211

Acute visits may not be part of continuous care, that defines G2211

Interested parties have presented reasons we find persuasive that such practitioners would not be likely to report HCPCS code G2211 with every O/O E/M visit they report. They reasoned that many practitioners delivering care in settings specifically designed to address acute health care needs, without coordination or follow-up, will regularly have encounters with patients that are not part of continuous care.