New CMS FAQ sheds additional light on compliant use of new HCPCS add-on code G2211

By Brian Murphy

 

Attention coders and mid-revenue cycle professionals: CMS has released a frequently asked questions (FAQ) document for new HCPCS add-on code G2211.

 

Link below.

 

My colleague Crystal May wrote an article about this interesting but troublesome new code (which went into effect Jan. 1), summarizing the guidance we had to date and offering up some of her own interpretation. I’ve also provided a link to that.

 

The FAQ is the latest, attempting to answer some of the lingering unanswered questions we’ve had since G2211 came onto the scene. It offers answers to 12 questions, including:

• When can I report HCPCS code G2211?

• In what office and outpatient settings can HCPCS code G2211 be billed?

• Can HCPCS code G2211 be billed when my patient sees another physician or practitioner in my group practice instead of me, including colleagues in the same specialty as me?

• Is it appropriate to bill HCPCS code G2211 using the Primary Care Exception?

• Can HCPCS code G2211 be billed in a Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC)?

• Is HCPCS code G2211 denied when modifier -25 is on the claim for any service?

• What must be documented for HCPCS code G2211? What does a billing/treating practitioner state in the patient record for the medical necessity of reporting HCPCS code G2211?

• What constitutes a serious or complex condition? What diagnosis must be used?

• What is the definition of “longitudinal”? Does it matter if the patient comes in once a year, every other year, or every 5 years, as long as the patient has selected that physician as their primary care doctor and who they call when they need care?

• Does patient cost-sharing apply to HCPCS code G2211?

• Can HCPCS code G2211 be reported during the same service period as care management services? Or, are these considered duplicative?

• Where can I find additional information?

 

You might wonder, why all the fuss? G2211 doesn’t pay very much. $16.04 is the latest I’ve heard. 

 

But most believe it will be billed in very high volume, based on the code description and its broad applicability. It’s an add-on code that can also be used in facility visits.

 

And therefore potentially denied in volume. 

 

CMS has to date not offered examples of sufficient medical record documentation to support the code, instead punting this to providers and their respective MACs. But it did confirm it will be monitoring use. As stated in the new FAQ:

 

“We have not specified any additional medical record documentation requirements for reporting the HCPCS code G2211 add-on code. Our medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and the patient care relationship as appropriate. We would expect that information included in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses, the practitioner’s assessment and medical plan of care, and/or other codes reported could serve as supporting documentation for billing HCPCS code G2211. Practitioners should consult their Medicare Administrative Contractor (MAC) regarding documentation requirements related to the underlying O/O E/M visit.”

 

Resources

 

• CMS, “Frequently Asked Questions (FAQs) About Office/Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-On HCPCS Code G2211”: https://www.cms.gov/files/document/hcpcs-g2211-faq.pdf 

 

• Norwood, “OM(G2211)! New HCPCS code leaves mid-revenue cycle professionals with lingering uncertainty”: https://www.norwood.com/omg2211-new-hcpcs-code-leaves-mid-revenue-cycle-professionals-with-lingering-uncertainty/