Practice Management: Billing & Coding — What’s the 411 on G2211?

On January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) made payable a new Healthcare Common Procedure Coding System add-on code: G2211. G2211 may be submitted alongside new and established office/outpatient evaluation and management (E/M) services. This will result in an additional 0.33 work relative value units (RVUs), or 0.49 total RVUs, per use (~$16).¹

Why Is This Important?

CMS recognized the complexity involved in providing a longitudinal relationship with patients to address ongoing health care needs. G2211 will help provide additional financial support to providers offering these services. G2211 was originally proposed in 2021; because of budget neutrality concerns and the estimated effects on physician payments, Congress delayed implementation until 2024.

What Is the CMS Code Description for G2211?

Visit complexity inherent to E/M 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 E/M visit, new or established.)

When Should G2211 Be Added to an E/M Visit?

Consider the add-on code for any new or established patient when you are the continuing focal point for all health care services the patient needs for a single, serious, complex condition. Per CMS guidelines (see https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule), the relationship between the patient and the physician is the determining factor of when the add-on code should be billed.

When Should G2211 Not Be Used?

• When your relationship with the patient is of a discrete, routine, or time-limited nature; for example, a physician who sees a patient for an acute concern should not report G2211 if they have not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time.
• When reporting Current Procedural Terminology (CPT) code 99211, which is defined as “Office or other outpatient visit for the E/M of an established patient that may not require the presence of a physician; usually, the presenting problem(s) are minimal” (this code is at times known as an “RN visit code”).
• When the office visit for an E/M service is reported with modifier 25 appended; Note: modifier 25 is used to indicate that a patient’s condition required a significant, separately identifiable E/M service above and beyond that associated with another procedure or service being reported by the same physician or other qualified health care professional on the same date (see https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf); in other words, modifier 25 is used to communicate 2 E/M services or a procedure plus an E/M service that are distinctly different but required for the patient’s condition to be appropriately reported and, therefore, appropriately paid (see https://www.ama-assn.org/system/files/issue-brief-cms-modifier-25.pdf).

Additional Tips

• CMS does not provide guidance for treating all neurologic disorders. Thus, there could be some interpretation in the use of the code. Neurologic disorders that are typically applicable include dementia, migraine, epilepsy, chronic inflammatory demyelinating polyneuropathy, multiple sclerosis, Parkinson syndrome, amyotrophic lateral sclerosis, and cerebral palsy.
• G2211 is not an American Medical Association CPT code. Commercial insurers may or may not pay for this add-on code. However, informal discussions across the country demonstrate that some commercial payers are paying when this code is added to appropriate E/M visits. It is in the interest of every practice to determine whether payment is available, as the total revenue on an annual basis may be substantial.
• Billing a patient when the code is not covered may generate an additional charge for the patient. If the code is covered, there may be additional patient responsibilities, including deductibles and coinsurance. It is important to develop a plan to determine appropriate billing practices.
• Whereas not explicitly stated by the CMS, the spirit of this code is to reimburse for longitudinal care of a serious or complex condition by the practice. This may include resident clinic patients and advanced practice provider patients if there is ongoing care within the practice.
• External to consistent diagnosis coding over time, CMS does not detail whether additional documentation is required to code G2211. As a result, for auditing purposes, the practice will need to decide whether additional documentation is warranted to demonstrate ongoing care related to a patient’s single, serious, or complex condition. This may be best included in the assessment and plan.
• Because this code may be used frequently by neurologists and other qualified health care practitioners, this code must be readily accessible within the electronic medical record system. The practice may benefit from developing a “quick click” option as part of the E/M billing process; that is, adding a button on the billing screen to include G2211 for quick access. Contacting the practice’s information technology staff person or electronic medical record vendor may be needed if customization is not readily available.
• Clinicians should exercise caution, because some electronic medical records systems may automatically associate G2211 with all diagnoses attached to the encounter. As such, users of this code may need to unclick diagnoses that should not be associated with G2211 before closing the encounter. Furthermore, if a longitudinal relationship for the appropriate condition is not established, the code should not be used.
• G2211 does not require any additional modifiers.