CMS releases G2211 FAQ: Finally!

Eight months after implementing G2211 CMS has released a FAQ document answering questions they’ve received via email and during Open Door Forums. The link is below. Some of the document reiterates information from the Federal Register and MLN Matters article, and some is new.

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)

• Use G2211 only 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.
• CMS says to think 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….”