OM(G2211)! New HCPCS code leaves mid-revenue cycle professionals with lingering uncertainty

By Crystal May, CCS, CPC, CDEO, CPMA, CRC, AAPC Approved Instructor

Senior Risk Adjustment Consultant, Norwood  

 

From the beginning, new HCPCS code G2211 has been surrounded by questions, uncertainty, and controversy. G2211 was supposed to be implemented in 2021, with CMS originally stating it would be “a single add-on code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.” 

Despite CMS’ efforts, Congress put a mandatory hold on G2211 until January 1, 2024. During this interim period there was much commentary and discussion in the healthcare industry, both for and against the use of the add-on code. By the time the code status was changed to active on January 1, 2024, CMS had already considered some discussions and made revisions. These included changes to the verbiage, limitations for billing, and some ambiguous guidance for how and when to apply it. 

While some could argue that additional scenario examples from CMS regarding the proper use of G2211 create more questions than answers, what we do know without question is that there will be further clarification over time. Frequent monitoring and timely application of any subsequent updates will be imperative for healthcare entities across the board. 

One of the basic tenets in the mid-revenue cycle space is that we cannot make assumptions. Decisions must be made based on complete and accurate documentation. Though most providers do their best to “think in ink” when creating documentation, any experienced revenue cycle professional will tell you that sometimes the verbiage required to draw correlation isn’t sufficient. 

Given the grey areas and uncertainty surrounding G2211, we have put together some bullet points below. These include what we currently know, allowable scenarios for reporting, exclusionary situations, and our best practice recommendations to keep in mind along the way while we all figure it out together as an industry.

G2211 official code description

HCPCS Code 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).

 

What we know so far

• It can be billed with office or other outpatient E/M services 99202-99205 and 99211-99215.
• It is intended to reimburse for the increased resources associated with the complexity of care and cognitive load required by providers who furnish consistent and continuous services for a patient’s overall healthcare or that of a single serious or complex condition. (e.g., a family medicine PCP managing multiple conditions over time, an endocrinologist managing care for type 1 diabetes with complications, an oncologist managing care for cancer, etc.) 
• It is not limited by specialty.
• CMS will reimburse $16.04 for G2211 starting 01/01/2024.
• It was added to the CMS Approved Telehealth services list.
• The code is not tied to clinical conditions but rather the overarching “longitudinal” relationship between provider and patient.

When can it be billed (with proper support)?

• When the E/M visit documentation supports an ongoing, comprehensive, continuous longitudinal relationship between the provider and patient where the provider has assumed responsibility for the overall management/coordination of the patient’s healthcare. 
• When the E/M visit supports ongoing care for a single, serious or complex condition such as HIV, sickle cell disease, etc. 

When should it NOT be billed?

• When there is no E/M on the same date of service. 
• When there is a lack of medical necessity documented. 
• When the E/M service has a payment modifier appended, such as modifier -25.
• When there is a lack of proper support for either the longitudinal relationship between provider and patient or the ongoing care of a single serious or complex condition(s). 
• When acute visits are for conditions of a transient nature, unless the provider has also assumed care for the patient’s overall healthcare management over time (with supportive documentation). 
• When visits are only of a discrete, routine, or time-limited nature, e.g., laceration, common cold, UTI, fracture, and other transient conditions. 
• When comorbidities are not present (or addressed) and/or when the billing provider has not assumed responsibility for the patient’s ongoing healthcare.

Potential Concerns

• G2211 is based on the provider’s cognitive work, the complexity of overall patient care, and the relationship between the two. Documentation may not sufficiently support the correlation between the cognitive process and the longitudinal relationship. 
• As coders and billers are unable to assume this correlation exists, documentation gaps are likely to occur with G2211. 

 

Questions to ask before billing G2211

• Does provider documentation support the requirements of the code? 
• Is the code applied correctly based on the most recent guidance from CMS? 
• Does your organization have billing holds in place to catch claims with G2211 for closer independent review by appropriately trained professionals?
• Do you have an audit plan in place for G2211?

 

Recommendations

• Create internal policies and procedures for documentation, coding, and billing of G2211 and ensure all staff are familiar with them.
• Implement billing edits to identify cases with G2211 for documentation review by trained coding, billing, and/or CDI professionals.
• Monitor all claims with G2211 to ensure proper payment and trend denials. 
• Concurrent CDI and auditing processes should be in place to ensure consistency and documentation compliance.

 

Given the amount of remaining uncertainty with G2211, we hope CMS will provide additional clarity and some more specific guidance soon. Until then proceed with caution, monitor trends, and watch for future updates.  

 

References

• American Academy of Family Physicians. (n.d.). G2211 Add-on Code: What It Is and How to Use It. Www.aafp.org. Retrieved January 24, 2024, from https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html
• Centers for Medicare & Medicaid Services. (2019, November 1). Finalized Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020 | CMS. Www.cms.gov. https://www.cms.gov/newsroom/fact-sheets/finalized-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar
• Centers for Medicare & Medicaid Services. (2023a, November 2). Calendar Year (CY) 2024 Medicare Physician Fee Schedule Final Rule | CMS. Www.cms.gov. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule
• Centers for Medicare & Medicaid Services. (2023b). Edits to Prevent Payment of G2211 with Office/Outpatient Evaluation and Management Visit and Modifier 25. https://www.cms.gov/files/document/mm13272-edits-prevent-payment-g2211-office/outpatient-evaluation-and-management-visit-and-modifier.pdf
• Centers for Medicare and Medicaid Services. (2024). How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211 Evaluation and Management (E/M) Visit Complexity Add-on Code G2211. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf

 

Like this article? Contact us

Need help with implementing G2211, or getting your risk adjustment evaluated for thoroughness and accuracy? Send an email to crystal@norwood.com.