The long-awaited G2211 code: What you need to know

January 15, 2024

There’s an important new code for 2024, and it pays (literally*) for you to know how and when to use it.

Up to this point, E/M coding has failed to take into account the resources, time, and cost incurred by providers in coordinating care over time for their patients. This may not come as news to primary care physicians, but in serving their patients the average primary care doctor has to coordinate care with nearly 230 other physicians spread across 117 practices.1

After a three-year implementation delay, CMS has officially instituted G2211—an add-on code that accounts for the reality that serving as the focal point of care requires providers to incur additional costs that should be compensated.

As AAFP put it back in late 2020, when the new code was first proposed: “CMS believes code G2211 reflects the time, intensity, and practice expense required to build longitudinal relationships with patients and address most of their health care needs with consistency and continuity over long periods of time. In the context of primary care, CMS believes the code recognizes the resources inherent in holistic, patient-centered care that combines the treatment of illness or injury, the management of acute and chronic health conditions, and the coordination of specialty care in a collaborative relationship with a clinical care team.2

Before we get into the how and when, let’s look at the CMS Code Descriptor:

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).

1https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html

2https://www.aafp.org/pubs/fpm/blogs/gettingpaid/entry/g2211_summary.html

When to use this add-on code?

  • G2211 became payable starting January 1, 2024.
  • You may report this code separately with new and established office or outpatient E/M services involving patients (i.e. codes 99202-99215) for whom you are the focal point for all of the healthcare services they need. An ongoing relationship with the patient is the key determinant of when you can add G2211.
  • You may add it even when the E/M visit is done via telehealth, because CMS has permanently added the code to the Medicare telehealth list.

When NOT to use this HCPCS code?

Some examples from CMS:

  • Care is furnished by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature (e.g. mole removal or referral for mole removal);
  • Treatment of a simple virus;
  • Counseling related to seasonal allergies;
  • Initial onset gastroesophageal reflux disease;
  • Treatment for a fracture;
  • Treatment in which comorbidities are either not present or not addressed;
  • Situations in which the billing professional has not taken responsibility for ongoing medical care for that patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that patient with consistency and continuity over time;
  • CMS will not allow payment for G2211 when the E/M service is billed with modifier 25. However: You can bill with modifier 25 appended for separately identifiable E/M visits occurring on the same day as a minor procedure and involving resources sufficiently distinct from the costs associated with that reimbursement.
  • You can bill private payers, but be aware that they are not required to cover and pay separately for G2211. Their policies will vary, so review your contracts with these payers before adding this code.

At a time when costs are rising and reimbursements are shrinking, it’s nice to find that providers can receive some additional compensation for the “extra-mile services” they provide in coordinating care for patients. If you know how to apply this new code properly, you open the door to added practice revenue.

*The 2024 national Medicare allowable for G2211 is $16.04.

 

More resources:

G2211: Coding Tips | AAFP 

The new Medicare G code: Everything you need to know to take advantage of it | AAFP 

Complexity Add-on Code G2211 – JF Part B – Noridian (noridianmedicare.com) 

 

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coders@calmwatersai.com

 

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Michelle Sergei-Casiano
Michelle Sergei-Casiano
Michelle Sergei-Casiano
CPC, CFPC, CEMC Senior Manager, Regulatory and Coding Compliance coders@calmwatersai.com

 

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