April 1, 2024
G-2211 Do’s and Don’ts
DEFINITION:2
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, or complex condition (add-on code, list separately in addition
to office E/M visit, new or established)
BACKGROUND:
G2211 includes services enabling practitioners to build longitudinal relationships with all patients (not only those
patients who have a chronic condition or single, high-risk disease) and to address most patients’ health care needs with consistency and continuity over longer periods of time. CMS believes that this code should reflect the time, intensity, and practice expense resources involved when practitioners furnish the kinds of office, outpatient E/M office visit services that enable them to build longitudinal relationships with all patients3. As of January 1, 2024, its Medicare Fee For Service national payment rate is $16.05 with a wRVU of 0.33. As of March 1, 2024, three national payers have confirmed coverage of G2211:
- Cigna (Medicare Advantage only),
- Humana (commercial and Medicare Advantage),
- United Healthcare (commercial and Medicare Advantage).
- WHEN TO USE
- Code G2211 can only be added to office/outpatient E/M visits (99202-99205 or 99211-99215) based on the clinician's continued responsibility for the patient, not based on the patient's clinical condition.
- A new patient visit can qualify when the patient will be establishing with the clinician as their medical home, and an acute care visit with an established patient can qualify if the clinician's practice serves as the continuing focal point for all needed health care services.
- G2211 may also be used in instances where a “patient's overall, ongoing care is being managed, monitored, and/or observed by a specialist for a particular disease condition.”1
- CMS has not required any additional documentation to support code G2211. However, if there might be any doubt about the longitudinal patient relationship (or intent to provide longitudinal care), it may be helpful to demonstrate it in the visit note.
- In a group practice, as long as the individual practitioner is meeting these requirements, even though multiple practitioners are seeing this patient in a group practice, G2211 would seem to be appropriate.
- WHEN NOT TO USE
- Non-office E/M visits,
- Urgent care center visits (i.e., one-off visits),
- Transitional care management visits,
- Medicare annual wellness visits,
- Visits requiring modifier 25 (i.e., services that when reported on the same date as an office/outpatient E/M service necessitate adding modifier 25 to the E/M code). Examples:
- Annual wellness visit (G0438-G0439),
- Injection of medication (96372),
- Spirometry, inhalation treatment, or other pulmonary function services (94010-94799),
- Osteopathic manipulative therapy (98925-98929),
- Annual alcohol misuse screening (G0442),
- Annual depression screening (G0444),
- High-intensity behavioral counseling to prevent sexually transmitted infection (G0445),
- Annual, face-to-face intensive behavioral therapy for cardiovascular disease (G0446),
- Face-to-face behavioral counseling for obesity (G0447).
SUMMARY:
The complexity code G2211 is utilized to identify the inherent costs involved when clinicians are the continuing focal point for all needed services, or ongoing care related to a patient’s single, serious condition or a complex condition.
REFERENCES:
- Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78970. https://www.federalregister.gov/d/2023-24184/p-1379
- https://www.aafp.org/pubs/fpm/issues/2024/0300/coding-g2211.html
- https://www.healthicity.com/blog/your-guide-g2211-billing-key-principles-and-practices