HCPCS Level II add-on code G2211 recognizes the significant and ongoing relationship between a patient and their physician. It compensates for the additional time and effort involved in managing the complexities of long-term patient care. This includes activities such as patient conversations, development of comprehensive care plans, and collaborative decision-making. This article explores the billing complexities associated with G2211 when used alongside office and outpatient evaluation and management (E/M) services (CPT 99202-99215), changes for 2025, and how to implement this code in your practice.
Recognizing the Physician-Patient Relationship
The purpose of G2211 is to compensate physicians and non-physician practitioners (NPPs) for the time and resources required to maintain long-term relationships with patients. The complexity of the visit tied to G2211 is distinct from medical decision-making (MDM), which is used to determine the level of E/M services. Unlike MDM, G2211 is based on the cognitive load of a physician’s ongoing responsibility to manage a patient’s care over time. This includes proactive care management, which goes beyond immediate or acute care.
Billing and Coding Requirements
Although G2211 was introduced in 2021, Medicare Part B began reimbursing for it on January 1, 2024. Many Medicare Advantage plans have also approved coverage, although it may vary by plan. Medicaid and commercial payers are not obligated to reimburse for G2211. To ensure proper reimbursement, practices should regularly review payer contracts and fee schedules to determine which insurers will reimburse for this code.
In the 2024 Medicare Physician Fee Schedule (MPFS) final rule, the Centers for Medicare & Medicaid Services (CMS) clarified that G2211 would not be reimbursed if the associated E/M visit is appended with modifier 25 (indicating a significant, separately identifiable E/M service). However, based on feedback from the medical community, CMS revised its policy in the 2025 MPFS final rule, allowing payment for G2211 when reported with the same-day E/M services (CPT 99202-99205, 99211-99215) for the following:
- An initial preventive physician examination or annual wellness visit
- Vaccine administration
- Any other Medicare Part B preventive service
There are no limitations on the frequency of billing G2211, provided the requirements are met. Any physician or NPP who may report E/M services in office or outpatient settings is eligible to bill G2211. However, it is important to note that G2211 is not reimbursable for services provided in rural health centers or federally qualified health centers.
Who Should Bill G2211?
Physicians or NPPs should bill G2211 if they are the primary provider coordinating all necessary care, such as a primary care physician, or if they are providing ongoing care for a single complex or serious condition.
Documentation Requirements
Although CMS has not outlined specific documentation standards for G2211, it is essential to include the following elements in medical records to ensure compliance:
- Reason for the visit
- Medical necessity for the E/M service provided
- Medically reasonable and necessary care to support the use of G2211, including a detailed medical history, claims history for ongoing diagnoses, and a comprehensive assessment and plan. Additional relevant service codes may also be necessary.
When auditing G2211 claims, focus on identifying the necessary elements and visit complexities that demonstrate an ongoing provider-patient relationship.
Required elements
- Reason for visit
- Medical necessity for E/M service
- Assessment and plan
- Intent for on-going, continued care
- Focal point management
- Care management beyond routine acute care
Visit Complexity
- Recommendations
- Impact of existing co-morbid conditions
- Coordinating Care
- Patient Education
- Importance of following instructions/plan of care
- Shared decision making
- Shared commitment toward goals
- Follow-up plan (when, where, who with , and what to bring)
Training, Implementation, and Monitoring
To ensure accurate and efficient use of G2211, healthcare practices should adopt a comprehensive approach that includes training, implementation, and monitoring:
- Training:
- Providers should be trained to document services that meet the criteria for G2211. This includes capturing the complexities associated with long-term patient relationships. Coders also need to understand how to identify eligible visits and ensure that documentation aligns with CMS guidelines.
- Implementation:
- Electronic health record (EHR) templates should be updated, and workflows should be refined to capture G2211-related services. Clear processes must be in place to support the documentation of long-term care management.
- Monitoring:
- Regular audits should be conducted to assess the use of G2211, monitor claim patterns, and analyze utilization by providers. Feedback should be provided to stakeholders to improve accuracy and ensure compliance.
By integrating these key components, healthcare organizations can effectively use G2211 to enhance patient care, ensure compliance, and optimize reimbursement.