In January 2024, the Centers for Medicare & Medicaid Services (CMS) issued guidance regarding the implementation of HCPCS add-on code G2211. This code is designed for office and outpatient (O/O) evaluation and management (E/M) visits that are inherently complex due to the medical care required. G2211 applies when care involves continuous collaboration for a patient’s ongoing health condition, particularly when it requires the specialized expertise of a physician or practitioner.
Key Aspects of G2211
What qualifies as a complex or serious condition?
CMS does not require a specific diagnosis to bill G2211. Instead, it is based on the continuous, active involvement of the physician or healthcare practitioner in managing a patient’s health. The complexity arises from the collaborative care provided, including patient education, care planning, and setting goals for health outcomes.
What is considered “longitudinal care”?
Longitudinal care is not specifically defined by CMS, but it refers to continuous, long-term care where the physician or practitioner is responsible for ongoing care management. If a physician or practitioner maintains a consistent relationship with the patient, managing their care over time, it may be eligible for G2211 billing.
Can a patient see a different physician/practitioner in the same group?
Yes, as long as the patient is receiving continuous care from the same group practice, even if the care is delivered by a different physician or practitioner within the same practice. If the requirements of G2211 are met, it is appropriate to bill for this code.
When should G2211 not be billed?
G2211 should not be billed in certain scenarios, including:
- Services like hospital inpatient, emergency room, skilled nursing, or home services.
- When billing for procedures such as blood draws or anesthesia services.
- If the physician does not have an ongoing, comprehensive relationship with the patient.
- If G2211 is being reported with an E/M CPT code other than 99202-99205 and 99211-99215.
How can physicians mitigate risk when billing G2211?
To ensure compliance and avoid billing errors, practices should consider:
- Educating physicians and staff on proper billing for G2211.
- Establishing an audit process for G2211 claims.
- Creating internal documentation policies to support the use of G2211.
- Monitoring billing software and reviewing the chargemaster for correct usage.
Clinical Scenarios Supporting G2211 Billing
Appropriate Scenarios:
- An established patient with chronic hypertension visits for an upper respiratory infection, during which the physician educates the patient about medication compliance and potential side effects.
- A new patient with diabetes and chronic kidney disease sees a new primary care provider, where a comprehensive treatment plan is discussed, including patient education and follow-up care.
- A nurse practitioner follows up with a patient with diabetes and congestive heart failure, discovering a new foot ulcer and adjusting treatment accordingly.
Inappropriate Scenarios:
- An established patient visits for an annual wellness exam, during which management of heart failure and diabetes is discussed. (G2211 cannot be coded with wellness visits like G0438.)
- A new patient is referred to a neurologist for pain management, but no ongoing care relationship is established.
- A patient with chronic conditions receives treatment for a knee injury, and a procedure is performed (modifier -25 applies, but not G2211).
Who Can Bill for G2211?
Any medical professional who provides O/O E/M services (CPT codes 99202-99205 and 99211-99215) in outpatient settings, including non-facility or telehealth settings, can also bill for G2211, provided the criteria are met. However, G2211 cannot be billed if modifier -25 is used for the same day’s services.
CMS Proposal for 2025: CMS is proposing to allow G2211 billing in conjunction with annual wellness visits or vaccine administration, even if modifier -25 is applied. Providers should monitor the 2025 Outpatient Prospective Payment System (OPPS) Final Rule for updates.
Documentation Requirements
To successfully bill for G2211, thorough and accurate documentation is essential. Documentation should include:
- Evidence of ongoing care for a complex or serious condition.
- A comprehensive treatment plan, including goals and expected outcomes.
- Clear confirmation that the physician is the continuing focal point of care.
Claims should reflect the continuity of care over time, supported by medical records, patient history, and treatment plans. This ensures that the code is used appropriately and in compliance with CMS requirements.
FAQ:
1. What conditions qualify for billing G2211?
G2211 applies to situations where a physician or healthcare practitioner provides continuous, collaborative care for a complex or serious health condition, not tied to a specific diagnosis.
2. Can I bill G2211 for a patient seen by a different provider in my practice?
Yes, as long as the care provided is continuous within the same group practice and meets the criteria for G2211.
3. What if I bill G2211 with modifier -25?
If you report modifier -25 for a procedure, G2211 cannot be billed on the same day for the same patient and by the same provider.
4. Can G2211 be billed for wellness visits?
No, G2211 cannot be billed with wellness visits such as G0438. It can only be billed with specific E/M codes like 99202-99205 and 99211-99215.
5. What documentation is required for G2211 billing?
Documentation must support the ongoing, longitudinal care of a patient with a serious or complex condition, showing the physician’s continuous involvement and the medical necessity of the services provided.