G2211 Visit Complexity Code: Simplified Requirements for Reimbursement

G2211 Reimbursement

G2211 visit complexity is now payable.  We explain the requirements in simplified easy to understand rules to ensure proper reimbursement.

The moratorium on Medicare payment for G2211 issued under the Consolidated Appropriations Act in 2021 ended December 31, 2023, and is now reimbursable.  As a result, G2211 now has a payment status indicator “A” and is separately payable.  Medicare estimates G2211 will be billed with 90% of outpatient office visit codes among certain specialties and roughly 58% of all office outpatient E/M services.  Based on CMS calculations, primary care will have a higher utilization of the add-on code, and surgical specialties will have the lowest utilization because they are less likely to establish longitudinal care relationships with the patients.

The purpose behind G2211

Evaluation and management codes are widely used and do not fully distinguish or account for longitudinal care for complex patients. As a result, the intensity of those E/M services cannot fully be captured through the RVU or reimbursement and is simply unrecognized. CMS has recognized this gap, and G2211 is an attempt to describe the resources and costs incurred for the intensity of services provided within those types of visits.

G2211 is appropriate when an E/M service is associated with medical care that serves as the continuing focal point for all needed health care services and/or with medical care that is part of ongoing care related to a patient’s single, serious condition, or complex condition.  For example, this could be a patient seeing a neurosurgeon for a stroke or back procedure and receiving physical therapy.  A pain management physician and the patient is receiving injections and continuing monitoring.  These are two examples of a single condition, which could be serious or complex.

When You Can Bill G2211

Medicare clarified in the Final Rule (88 FR 78979) that the add-on code G2211 is based on the relationship between the patient and the practitioner, and that is the determining factor of when the add-on code is to be billed.

The continuing focal point for all needed health care services is the relationship between the patient and the practitioner. This is where the patient receives care for the health care services that the patient needs.

Medicare provides a clinical example to illustrate the focal point:

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.

The focus here is not the sinus congestion; instead, Medicare recognizes the longitudinal relationship in the diagnosis, treatment plan, and the doctor-patient relationship.  Different courses of treatment may be considered or recommended, from conservative with no prescriptions to something beyond that.  The patient relationship is critical from a longitudinal perspective of future care and trust.  Medicare has recognized all of these factors in the rule-making process, from the doctor’s approach, best outcomes, building trust, and having a trusting longitudinal relationship for all primary care needs.  These were not lost on Medicare; while what seems like a simple visit, the overall interaction is inherently complex. Yet, if you end up with no prescription, whether it is an established patient or even new, those complexities are not well captured under the E/M.  The add-on code G2211 was built to recognize and capture these complexities.

The second part of the add-on code describes the relationship between the partitioner and the patient.  Part of the code description is “ongoing care,” representing the longitudinal relationship between the patient and the practitioner.

Medicare provides an example to illustrate the relationship portion of the code:

A patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the last month.

In contrast to the sinus congestion example, the infectious disease physician is providing care described in the code description, which states in part, “medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”  Here, the physician is part of the ongoing care of a single condition.  Physicians have similar factors to consider regarding how they will approach the patient, the words they use, the tone of their response, and how they communicate regarding missed doses.  The physician needs to maintain a trusting environment and hopefully open communication from the patient.  In this example, even though the infectious disease physician is not the focal point for all health care services, HIV is a single, serious condition, and/or complex condition.  Presuming the patient and doctor relationship is ongoing, G2211 would be appropriate.

CMS expressly stated the most important component in determining whether to bill the add-on code G2211 is the relationship between the practitioner and the patient.  If there is a focal point for all needed services, like primary care, or if the provider is part of a single, serious, and complex condition, it would be appropriate to bill the add-on code.  The add-on code is to capture the inherent complexity of visits from the longitudinal relationship with the patient.

Can Any Specialty report G2211

CMS has clarified that “unequivocally,” G2211 is not restricted to specific medical specialties. The add-on code can be reported by any specialty reporting office visit E/M code when the provider is the focal point of care or part of ongoing care related to a patient’s single, serious, or complex condition.

The G2211 Documentation Requirements

In 2019, Medicare established that it would not require specific documentation requirements to minimize the burden on providers. CMS stated in the 2019 Final Rule that the medical record or claims history for a patient/practitioner combination, such as diagnosis, the practitioner’s assessment and plan for the visit, and/or other service codes billed, could serve as supporting documentation.

The patient relationship codes established under MACRA and finalized in the 2018 Final Rule could be used as evidence in the claims record to support the add-on code G2211. The Level II HCPCS modifier defines and distinguishes the clinician’s relationship and responsibility.

G2211 Modifiers – Does CPT code G2211 need a modifier

G2211 is an add-on HCPCS Level II code that can only be reported with CPT codes 99202-99215. It does not require a modifier.  However, G2211 cannot be reported when an E/M code has modifier 25 appended to the office visit.  CMS has created an edit to deny G2211 when reporting with an E/M that has modifier 25.  Contractors will issue a denial code CO with a claim adjustment reason code 234.  There are no other modifier restrictions with this code.

Can G2211 Be Billed With an Office Visit Provided Via Telehealth

G2211 is reportable with E/M services provided via telehealth.  CMS has updated the list of telehealth services, adding G2211 to telehealth.  The complete list of telehealth services payable under the Medicare Physician Fee Schedule can be found here.

The RVU for G2211 and National Reimbursement Amount

Total RVU is 0.49, and wRVU is 0.33, with Medicare national rate reimbursement of $16.04.  The reimbursement rate will vary based on locality.  For example, the Michigan Locality 01 fee schedule is $16.48 for a participating provider, and the Michigan Locality 99 fee schedule is $15.75 for a participating provider.  To access your locality and know the exact Medicare reimbursement amount for G2211, you can search using the Medicare Physician Fee Schedule Database (MPFSDB/Fee Schedule Look-Up).

When G2211 Should Not Be Reported

In short, G2211 should not be reported when the E/M service is discrete, time-limited in nature, or routine as described by CMS.  Some examples CMS has provided include but are not limited to a mole removal, referral to a physician for removal of a mole, counseling related to seasonal allergies, treatment of a fracture, the billing provider has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or the provider does not plan to take responsibility for subsequent ongoing medical care for that specific patient with consistency and continuity over time.

Reporting the add-on code with these types of visits would be inconsistent with the code, which describes care as a continuing focal point and/or part of ongoing care.