Table of Contents

• • G2211 FAQ
  • Changes to G2211 in 2025 and 2026
  • Not all visits
  • Clinician’s relationship with the patient, type of problem
  • Acute condition, seen in primary care
  • CMS expected frequency
  • Q&A from CodingIntel’s August 17, 2023, CMS Proposed Rule Webinar

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 home or residence service or office/outpatient evaluation and management visit, new or established)

• Use G2211 on codes 99202—99205 and 99211—99215, in any outpatient setting, facility and non-facility. No separate payment for RHCs or FQHCs. G2211 can be reported when using the primary care exception in teaching physician situations.
• Beginning in January 2026, G2211 may be added on to home and residence services codes 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350 Updated definition above.
• CMS reminds us it is  about the relationship between the practitioner and the patient, and restates that the relationship is either being the focal point for all needed care (primary care) or providing care for a single, serious, complex condition.
• If there is a patient care team within a group practice, and a member of the team sees the patient “it may be appropriate to report HCPCS code G2211.” CMS doesn’t say “it is appropriate” they say “may be appropriate.
• There is no specific definition of “longitudinal care.”
• G2211 may be reported during the same service period as care management services.

Serious or complex condition

• In response to a question about what constitutes a serious or complex condition, CMS says no specific diagnosis is required. It does require “a continuous and active collaborative plan of care related to an identified health condition—the management of which requires the direction of a practitioner with specialized clinical knowledge, skill and expertise.” There are two examples: infectious disease physician caring for a patient with HIV and practitioner who is caring for a patient with sickle cell disease.

What about documentation?

• “We have not specified any additional medical record documentation requirements for reporting the HCPCS code G2211 add-on code.” CMS says medical reviewers “may use” documentation to confirm the medical necessity of the visit and the patient care relationship. CMS expects that information “in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses, the practitioner’s assessment and medical plan of care, and/or other codes reported could serve as supporting documentation.”
• Translated, I interpret this to mean if you are the infectious disease physician seeing a patient for HIV, and the medical record shows that treatment, and the claims history shows visits over time, that would meet the requirement.
• CMS allows G2211 for new patients, when the practitioner “intends” to have a longitudinal relationship. It would make sense to include in the assessment and plan the follow up. “Follow up every six months for xxx or return to the clinic….”

CMS Document link:
https://www.cms.gov/files/document/hcpcs-g2211-faq.pdf

Changes to G2211 in 2025 and 2026

Beginning 1-1-2025 claims with modifier 25 would be payable when the service performed in addition to the office visit is an annual wellness visit, vaccine administration or other CMS covered preventive medicine service.

• 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. CMS is emphasizing the longitudinal relationship between the practitioner and the patient.
• Beginning in 2026, G2211 may be used with home and residence services.

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.” 2024 PFS p. 428, Final 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.

Want a second opinion? Read what Dr. Ronald Hirsch has to say here:

https://icd10monitor.medlearn.com/code-g2211-another-opinion-and-several-questions/

Documentation

CMS issued a MLN article  13473 Jan. 18, 2024 and answered the question we’ve all been asking.  I’ll just post it here.  I’ve bolded one sentence. This is what I’ve been saying at our webinars. The visit itself must be medically necessary.

Documentation Requirements

You must document the reason for billing the O/O E/M visit. The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We haven’t required additional documentation. Our medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time you spent. 

These items could serve as supporting documentation for billing code G2211:

• Information included in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses
• The practitioner’s assessment and plan for the visit
• Other service codes billed (MLN Matters 13473 Jan 18, 2024)

Not all visits

CMS won’t pay for the add-on code when used with modifier 25, on the date of a minor procedure.

CMS also states that not all E/M would be eligible. “…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…” . They provide specific examples of conditions that would not require the add on complexity code: mole removal, treatment of a simple virus, seasonal allergies, new onset GERD, treatment for a fracture, 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.” p. 432 Final Rule.

Clinician’s relationship with the patient, type of problem

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

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

The section of the CMS 2024 Final Rule that describes G2211 is from page 428–445

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. See the CMS document released in August 2024, described and linked at the top of this article.

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 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:  Neither the Proposed or Final Rule named 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.

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

• Answer:  Look at the MLN Matters article and the FAQ.  This is discussed at the top of this article.
• https://www.cms.gov/files/document/hcpcs-g2211-faq.pdf
• https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf

The Q&A content above is accurate as of the date published (January 22nd, 2024).