CMS will pay for add-on code G2211 in 2024 (effective date 1-1-2024)
Table of Contents
- 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
- Q&A from CodingIntel’s January 22nd, 2024
This information is from the 2024 Final Rule, released Nov. 2, 2023.
- 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.
- CMS will not allow G2211 to be used with an E/M service if modifier 25 is appended to the E/M service
- With budget neutrality, there is pressure on Congress from some specialties not to allow implementation. We’ll see what Congress does in their year end spending bills.
- MLN Matters 13473 discusses documentation for G2211. Page down.
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. 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.
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
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.
Acute condition, seen in primary care
This surprised me. From page 429.
“We clarify that it is the relationship between the patient and the practitioner that is the determining factor of when the add-on code should be billed. First, the “continuing focal point for all needed health care services” describes a relationship between the patient and the practitioner, when the practitioner is the continuing focal point for all health care services that the patient needs. For example, a patient has a primary care practitioner that is the continuing focal point for all health care services, and the patient sees this practitioner to be evaluated for sinus congestion. The inherent complexity that this code (G2211) captures is not in the clinical condition itself— sinus congestion —but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.”
- G2211 can be used for treatment of acute conditions by a practitioner who provides ongoing, care. CMS is emphasizing the relationship between the patient and the practitioner.
- Again, CMS believes that the valuation of office visit codes doesn’t account for the practice expense of longitudinal care of patients.
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 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.
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.
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.
Q&A from CodingIntel’s January 22nd, 2024
Questions: Our MAC isn’t processing G2211 correctly
One: Not a support question or need. Just wanted to let Betsy know that our clinic has coded G2211 on several claims so far for Medicare Advantage plans and they are currently denying code as bundled without modifier 25 or any other modifier used. For example a 99214 is coded with G2211 and denied as bundled. I know there wasn’t a whole lot of information released for this code prior to use, so maybe this is helpful. Also, maybe editing software for these payers has not been updated for the use of new code or this code is only covered by traditional Medicare?
- Answer: There is so much wrong with this MAC processing, I don’t know where to start. I agree: they haven’t updated their software. Add-on codes don’t require modifiers. And, G2211 with modifier 25 should be rejected. I wish I had an answer for this.
Two: I tried using G2211 Jan 2 2024 and received this message (I assumed this could be used in 2024) “Smarteditpattern 4087 per CMS guidelines payment for procedure code G2211 is always bundled into payment for other services not specified and no separate payment is made.accepted for processing.”
- Answer: Clearly the MACs aren’t ready. Shocked, shocked. Seriously, in the next few weeks I expect the MACs or CMS to tell us if we need to resubmit or if they will reprocess. I suggest continuing to report G2211, in case they will reprocess them without any additional work on our part once they’ve updated their claims processing system.
Question: I am sure that we are all still a bit confused by what’s been published to date, and the interpretation is pretty subjective.
Scenario: Patient has been seen by pcp for several conditions for 20 years. She goes to the office complaining of possible fracture of finger. Xray confirms and provider sends patient to ortho. Would provider bill that visit with G2211? Based on current info, G2211 would be appropriate because of longitudinal relationship, however, the visit, and the diagnosis is ‘discrete.’ The alternative is that if the intent of the code is based on the relationship between the patient and the provider, G2211 would be used on every visit (when no procedure is performed). I appreciate your thoughts!! Thank you so much for always providing the best, most current information. I have followed you for many years, and hope to do so for many more!
- Answer: Page down in my article on G2211, https://codingintel.com/hcpcs-add-on-code-for-e-m-visit-complexity/ and read the example from the CMS Final Rule. The example is relevant.
Question: What about billing the G2211 in the home setting along with 99211-99215 or 99202-99205?? I cannot seem to find an answer to this question. Any help is greatly appreciated.
- Answer: You can’t bill office visit codes in the home. So no, you can’t bill it in the patient’s home.
Question: Can G2211 be billed with 99441 – 99443. G2211 is listed an an audio only accepted code for CMS.
- Answer: No. Bill only with 99202—99215.
Note: when CMS says bill with 99202—99215, take them literally.
Question: Good Morning! I would be interested in your input regarding circumstances where a
urologist can bill G2211. They have “discovered” this code and I want to be sure we have a
better understanding since they are not primary care providers. Any info would be greatly
appreciated.
- Answer: This article HERE will help you. Does your urologist have a longitudinal relationship with the patient?
This content is accurate as of the date published (January 22nd, 2024).
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