Implementing G2211 Code: Better Reimbursement for Complex Patient Visits

What is G2211?

For internal medicine and primary care physicians, the implementation of G2211 is a major victory. The new code allows doctors to be more appropriately reimbursed for complex patient visits. Centers for Medicare & Medicaid Services recognizes that there are inherent resource costs internal medicine and other clinicians incur when longitudinally managing a patient’s overall health, whether the patient’s treatment is a single, serious, or complex chronic condition.

Below is CMS’ Code Descriptor on 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/outpatient evaluation and management visit, new or established).

Long before CMS proposed the G2211 code in 2021, many medical societies have been advocating for a new code that would allow physicians and other clinicians to account for services like chronic disease management tracking, review of consultative or diagnostic reports, medication monitoring, safety outside of patient visits, and more.

With the final 2024 Medicare Physician Fee Schedule inclusion of G2211, the “time, intensity and practice expenses needed to meaningfully establish relationships with patients and address most of their health care needs with consistency and continuity” can now be properly reflected, according to CMS. Ultimately, we are pleased that the G2211 add-on code can support the improvement of patient and population health outcomes and strengthen the Medicare program.

Important things to consider: Documentation guidelines, uses, and reminders

In MLN MM13473, issued on January 18, 2024, CMS shared how to orient your billing staff on the correct use of HCPCS code G2211 and modifier 25, documentation requirements for G2211, and patient coinsurance and deductible. To start, you need to inform your billing personnel of the following details:

The first step is to check your relationship with your patient, ensuring that your staff notes down if you fit the following descriptions:

• You’re the continuing focal point for all needed services, like a primary care practitioner
• You’re giving ongoing care for a single, serious condition or a complex condition, like sickle cell disease or HIV

If this describes your doctor-patient relationship, then you will bill G2211. Remember, billing the add-on code does not rely on the clinical condition being treated, but the cognitive load of the continued responsibility of being the focal point for all needed services for your patient.

Let’s take the case of a patient with HIV: As their infectious disease physician, you learned that they missed several doses of HIV medication. This could’ve resulted in a change in their HIV medicine even though there was no issue with the original medication. However, since you’ve earned their trust and built a pleasant relationship over time, your approach will focus on cultivating trust and reminding them not to miss their doses. Considering how to approach this ongoing care for a single, serious condition or a complex condition such as HIV makes the E/M visit more complex; hence, you may bill G2211.

Apart from knowing when to use G2211, you should let your billing team know that the add-on code may not be reported without reporting an associated O/O E/M visit. G2211 isn’t payable when the associated O/O E/M visit is reported with modifier 25. 

In documenting G211, there is no required additional documentation, but you also have to educate your billing staff on the following documentation requirements. First, note down the reason for billing the O/O E/M visit, ensuring it is medically reasonable and necessary for the practitioner to report G2211. Second, you need to show the medical necessity of the O/O E/M visit and these supporting documents:

• Information included in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses
• The practitioner’s assessment and plan for the visit
• Other service codes billed

In the larger picture, Synapse is hopeful about the future of Medicare and the growing support for medical professionals. As one of the leading medical billing companies, we are always on the lookout for changes in the healthcare industry.  Our remarkable team of billing experts can help you stay on top of the fast-paced changes in billing codes. Partner with us today so we can shoulder the intricacies of billing and you can focus on providing the best services to your patients.