Medicare document

Complexity Add-on Code G2211

Effective January 1, 2024, complexity add-on code G2211 may be submitted with Evaluation and Management (E/M) office or outpatient (O/O) visits, 99202-99215.

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.

Documentation would support furnishing services to patients on an ongoing basis that results in care personalized to the patient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve the delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader healthcare landscape.

The complexity add-on code would support a long-term patient-provider relationship and would indicate the provider will be managing the patient’s health care over a long period. The provider would build a trusting patient-doctor relationship and be the continuing focal point for all needed health care services related to the ongoing patient’s single, serious condition or complex condition. Every patient would be unique with their health care needs and templated language for the add-on code may not support medical necessity. This is an important caveat as many EMRs have templated drop-down screens that consistently are used for “cut and paste” repeated information visit-to-visit and this is frowned upon to bill the G2211.

The code does not limit the type of provider based on specialties.

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 or outpatient E/M visit, new or established)

E/M with Modifier -25

Separately identifiable E/M visits billed with modifier -25 occurring on the same day as a minor procedure, have resources sufficiently distinct from the costs associated with that reimbursement. CMS will not allow payment for the add-on code G2211 when the E/M service is billed with modifier 25.

*There is a 2025 PFS proposed update that would allow G2211 with modifier 25 when an E/M service is done on the day of an annual wellness visit, immunization or other CMS-covered preventive service. This is a proposal, not a final rule yet. (Refer to MLN 13272 in resources.)

Examples included in CR13452

Example 1:

A patient has a primary care practitioner that is the continuing focal point for all health care services, and the patient sees this practitioner to be evaluated for sinus congestion. The inherent complexity that this code (G2211) captures is not in the clinical condition itself – sinus congestion – but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There is previously unrecognized but important cognitive effort of utilizing the longitudinal relationship itself in the diagnosis and treatment plan and weighing the factors that affect a longitudinal doctor-patient relationship.

In this example, the primary care practitioner could recommend conservative treatment or prescription of antibiotics. If the practitioner recommends conservative treatment and no new prescriptions, some patients may think that the doctor is not taking the patient’s concerns seriously and it could erode the trust placed in that practitioner. In turn, an eroded primary care practitioner-patient relationship may make it less likely that the patient would follow that practitioner’s advice on a needed vaccination at the next visit.

The primary care practitioner must decide, what course of action and choice of words in the visit itself, would lead to the best health outcome in this single visit, while simultaneously building up an effective, trusting longitudinal relationship with this patient for all their primary health care needs. Weighing these various factors, even for a seemingly simple condition like sinus congestion, makes the entire interaction inherently complex, and it is this complexity in the relationship between the doctor and patient that this code captures.

Example 2:

A patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the last month. The infectious disease physician has to weigh their response during the visit, the intonation in their voice, the choice of words to not only communicate clearly that it is important to not miss doses of HIV medication, but also to create a sense of safety for the patient in sharing information like this in the future. If the interaction goes poorly, it could erode the sense of trust built up over time, and the patient may be less likely to share their medication adherence shortcomings in the future.

If the patient isn’t forthright about their medication adherence, it may lead to the infectious disease physician switching HIV medicines to another with greater side effects, even when there was no issue with the original medication. It is because the infectious disease physician is part of ongoing care, and has to weigh these types of factors, that the E/M visit becomes inherently more complex, and the practitioner bills code G2211. Even though the infectious disease doctor may not be the focal point for all services, such as in the previous example, HIV is a single, serious condition, and/or a complex condition, and so as long as the relationship between the infectious disease physician and patient is ongoing, this E/M visit could be billed with the add-on.

To reiterate, the most important information used to determine whether the add-on code could be billed is the relationship between the practitioner and the patient. If the practitioner is the focal point for all needed services, such as a primary care practitioner, the HCPCS G2211 add-on code could be billed. Or, if the practitioner is part of ongoing care for a single, serious and complex condition (e.g., sickle cell disease), then the add-on code could be billed. The add-on code captures the inherent complexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship.

An example of when not to use the G2211 with an office visit. Even though this add on code is allowed with a new patient office visit, use with caution, since there has not been that “longitudinal relationship” established yet. Also, if you do not anticipate or expect the patient to return for follow up in the long term, it may also not be an appropriate add on.

If an established patient presents for a recheck appointment with no new problems or concerns to “address” and the chronic condition discussion is not a concern or contributory for this encounter of a simple or low level “recheck” it would be difficult to support the G2211 along with an E/M visit.

CMS also states that not all E/M’s would be eligible. “…E/M visit complexity add-on code would not be appropriately reported, such as when the care furnished during the O/O E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine or time-limited nature…” . They provide specific examples of conditions that would not require the add on complexity code: mole removal, treatment of a simple virus, seasonal allergies, new onset GERD, treatment for a fracture, and/or “when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.” p. 432 Final Rule 2024.

I have heard that many practices have taken some liberties when adding the G2211 to every single E/M when the patient comes in. I will continue to discourage that practice. Above all things, services need to be “medically necessary”, and patients will also have a share of cost attached to this add on. It is being reimbursed around $16.50 on average, but 2nd quarter 2024 already has several commercial plans taking it off their fee schedule. United Healthcare, specifically, put out in their June 2024 policy update newsletter to providers, “Effective with dates of service on or after September 1st, 2024, HCPCS code G2211 will be included within the UHC Commercial Rebundling Policy, Professional Claims: UHC’s reimbursement for the services associated with G2211 is included in its reimbursement for outpatient evaluation and management services and therefore G2211 is not separate reimbursable.”

I would expect more commercial plans to follow with the over-utilization of this code in the first quarter of 2024 after the rollout. Monitor your EOB for possible denials in the future. Also, listen for updates on my CodeCast Podcast, which publishes every Tuesday.

References