Decoding What’s Going on With G2211 and Modifier 25

Feb. 19, 2024

By David Tully
Vice President, AAFP Government Relations

Following the AAFP’s big win on G2211 at the end of 2023 and the Jan. 1 implementation of that Medicare add-on code — which pays more accurately for the complex, high-value visits that primary care physicians provide as part of a continuous relationship with a patient — the Academy started hearing from members who are frustrated by a wrinkle in the new policy: its exclusion from evaluation and management visits for which family physicians are used to coding modifier 25. 

“If the physician also persuades the patient to receive a vaccine (to prevent future illness) during the same visit, the physician would be unable to bill for G2211 because modifier 25 is required to report the immunization service on the same day as an E/M visit for sinus congestion,” we told CMS. 

We also cited an example from an AAFP member. 

“When a family physician trims the toenails of a patient with diabetes, they are unable to bill G2211 because the additional procedure requires modifier 25 be appended to the office/outpatient E/M visit,” the member wrote. “The family physician is penalized for offering comprehensive, same-day services to care for their patient — care that reinforces the physician’s longitudinal relationship with the patient as their primary source of care. 

“The current policy inadvertently reduces the incentive for physicians to fully address patient needs in a single visit. Returning for a second visit would also unfairly penalize Medicare beneficiaries who face additional out-of-pocket costs and spend additional time visiting the physician’s office a second time.” 

As we’ve often talked about in this space, budget neutrality — the stipulation that CMS can’t raise payment in any area of the MPFS without lowering it somewhere else — is a key obstacle here. With the meter running on Congress’ most recent continuing resolution to fund the government, the AAFP is again urging lawmakers to fix this outmoded mandate, which stifles investment in primary (and other medical) care and fails beneficiaries.  

Even absent such a correction, however, we’re arguing that CMS could, at minimum, reduce restrictions on the use of G2211 when preventive services are provided during an office visit for E/M services. For example, allowing G2211 payment with E/M services when modifier 25 is reported with common preventive services would put the total increase in Part B allowed charges at about $121 million, a reduction to the conversion factor of no more than about 0.1% to maintain budget neutrality — not an extraordinary price for achieving what’s in the best interest of Medicare beneficiaries and the primary care physicians who provide these valuable services. And eliminating the modifier 25 exclusion starts to look even more doable if CMS, as we’ve asked, examines actual 2024 utilization of G2211, which is likely to be lower than anticipated due to the large number of outpatient/office E/M visits reported with modifier 25 that are ineligible for G2211 payment. 

Besides advocating for more realistic use of G2211 and modifier 25, our Feb. 7 letter called for the 2025 Medicare physician fee schedule to  

• make permanent coverage of both audio-video and audio-only telehealth services for all beneficiaries regardless of geography; 
• pay telehealth services reported with either place of service 10 or 02 at the non-facility rate; and 
• expand the primary care exception — which permits a teaching physician to bill for some lower and midlevel complexity physicians’ services furnished by residents in specific types of residency training settings, even when the teaching physician is not present with the resident, if certain conditions are met — to include additional codes, as we have long advocated.  

“Permanently expanding the primary care exception could help improve utilization of recommended preventive care services, which is particularly important as many patients are still catching up on preventive care they may have forgone throughout the pandemic,” we noted. 

We are meeting with CMS leaders to discuss G2211 and how eliminating the modifier 25 policy is critical to achieving the goals of G2211 payment — advocacy that will continue until there is a solution. 

Family Medicine Advocacy Summit 

Registration remains open for our 2024 Family Medicine Advocacy Summit, May 19-21 in Washington, D.C. This is our biggest in-person advocacy event of the year, where AAFP members join colleagues in their chapters for face-to-face conversations with members of Congress about the Academy’s top legislative priorities. In an election year when we’re already working on some pivotal issues, I can’t overstate the value of your participation.  

Another Way to Be Heard About Payment

In November, I put in a plug for the Physician Practice Information Survey, which gathers data on practice costs helping us advocate to improve physician payment. It’s run by the AMA, in tandem with the consulting firm Mathematica, and endorsed by more than 170 medical societies and other health care associations.  

In late January, the AMA sent nearly 10,000 physician practices a reminder to complete the survey. Practices chosen to participate will see the return address ppisurvey@mathematica-mpr.com and a priority mail packet from Mathematica with a link to the survey and supporting information. If you received this email, please fill out the survey. The information you provide — about the time you spend on patient care each week — is extremely important to the AAFP’s push for accurate payment.