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

    Update: After delaying it for three years, the federal government implemented code G2211 on Jan. 1, 2024. For more on how and when to use the code, see this FPM article

    The Centers for Medicare & Medicaid Services (CMS) has finalized its new add-on code for visit complexity, which should be a financial boon to primary care doctors. All family physicians should be aware of the code, G2211, and use it appropriately on a frequent basis starting in 2021. Here’s what you need to know to take advantage of it.

    Code G2211 describes “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.” In short, G2211 is for evaluation and management (E/M) visits that are part of an ongoing, longitudinal care relationship. It is an add-on code that you may list separately in addition to office/outpatient (E/M) visits for new or established patients (i.e. codes 99202-99215). 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. The code’s Medicare payment allowance will be approximately $15.88, but will vary geographically.

    CMS is not restricting the code’s use to certain specialties, but assumes some specialties will furnish these types of services more than others. In fact, CMS assumes physicians who rely mainly on office/outpatient E/M visits will report G2211 with 90% of those visits.

    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.

    As an example of the use of code G2211 in a primary care setting, CMS describes an established patient visit with a 68-year-old woman on multiple medications who has progressive congestive heart failure (CHF), diabetes, and gout. The physician discusses the patient’s current health issues, which includes confirmation that her CHF symptoms have remained stable for the past three months. She denies having symptoms of hyper- or hypoglycemia but notes ongoing pain in her right wrist and knee. The physician adjusts the dosage of some of the patient’s medications, instructs her to take acetaminophen for her joint pain, and orders laboratory tests to assess glycemic control, metabolic status, and kidney function. The physician also discusses age-appropriate disease prevention with the patient and orders a pneumonia vaccination and colonoscopy screening.

    CMS notes that in this example the physician is serving as the focal point for the patient’s care: addressing the broad scope of the patient’s health needs by furnishing care for some or all of the patient’s conditions across a spectrum of diagnoses and organ systems with consistency and continuity over time.

    CMS also offers examples of visits for which reporting code G2211 would not be appropriate, such as:

    • Care 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.

    There are other situations in which reporting G2211 may not be expressly prohibited, but probably should not be done, such as when a procedure is performed in addition to the visit and a -25 modifier is used. In that scenario, the procedure code would be expected to cover much of the work/expense.

    CMS will use Medicare claims data to gauge whether the use of G2211 was appropriate. For example, when physicians separately report care management services for beneficiaries, it would be appropriate for them to report the G2211 add-on service, because care management claims indicate an ongoing, continuous relationship with the patient. Likewise, when patients return to the same physician for routine preventive services that will indicate to CMS that the physician has taken responsibility for ongoing medical needs for that patient. CMS also believes the use of patient relationship codes could provide further evidence in the claims record to support the use of code G2211. Patient relationship codes are Level II HCPCS modifiers that help define the relationship of a physician with a patients at the time the physician furnished a service and allow physicians to self-identify their patient relationships.

    — Samuel Le Church, MD, American Academy of Family Physicians (AAFP) CPT Advisor, and Kent Moore, AAFP Senior Strategist for Physician Payment

    Posted on Dec. 17, 2020 by Kent Moore

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.