Begining Jan. 1, 2024, qualified healthcare providers can bill an add-on HCPCS Level II code to report the extra time, effort, and associated practice expense involved with caring for Medicare patients across the continuum of healthcare.
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).
Before you begin to bill for this service, however, there are a few things to consider:
- Providers billing the add-on code are expected to provide longitudinal care to the patient.
- Providers who do not intend to have an ongoing longitudinal relationship with the patient (e.g., urgent care, consultants, second opinions, etc.) should not bill G2211
- Primary care physicians and specialists may bill this add- on code
- Bill G2211 in conjunction with an office or other outpatient evaluation and management (E/M) (CPT code 99202 to 99215)
- Add-on code G2211 may be billed with telehealth
- Do not bill G2211 when the E/M service is reported with modifier 25 for a procedure rendered by the same
- Do not bill G2211 when chronic/complex conditions are documented but not considered or addressed in the E/M of the patient.
To bill the service, the work should be documented as performed. Documentation should identify the history, the current treatment plan, goals of care, and any previously memorialized similar episodic events with adverse outcomes. In addition, concerns and/or considerations of the current episode of care. Updates to the Longitudinal Care Plan for this episodic event should be included.
Serious | Complex Condition
The key is also the term “ongoing.” Ongoing would infer that this is a condition that the provider actively manages for the patient, and the problem(s) require complex management due to the seriousness of the healthcarerelated issues.
Episodic Care | Episodic Care Plan
When treating a problem addressed “today,” this is episodic care. It is care provided per episode. The Episodic Care Plan (ECP) would then be the treatment plan created to treatment of the problem(s) addressed.
Longitudinal Care Plan | Management
Plan: A consolidated, active, and thorough plan that includes the current treatment, goals, and plans regarding serious and/or complicated conditions.
Management: Caring for the patient episodically and/or through direct care of a single serious/complex problem with updates to the care plan.
As per CMS ” G2211 includes the services that enable practitioners to build longitudinal relationships with all patients (that is, not only those patients who have chronic condition or single, high risk disease) and address the majority of patient’s health care needs with consistency and continuity over long periods of time”.
When To Bill G2211 add-on code
Think about the relationship between you and the patient when deciding to bill G2211. Bill G2211 if:
• 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
Example 1: A patient sees you, their primary care practitioner, for sinus congestion. You may suggest conservative treatment or antibiotics for a sinus infection. You decide on the course of action and the best way to communicate the recommendations to the patient in the visit. How the recommendations are communicated is important in that it not only affects the patient’s health outcomes for this visit, but it also can help build an effective and trusting longitudinal relationship between you and the patient. This is key so you can continue to help them meet their primary health care needs.
The complexity that code G2211 captures isn’t in the clinical condition – the sinus congestion. The complexity is in the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There’s important cognitive effort of using the longitudinal doctor-patient relationship itself in the diagnosis and treatment plan. These factors, even for a simple condition like sinus congestion, make the entire interaction inherently complex. In this example, you may bill G2211.
Example 2: A patient with HIV has an office visit with you, their infectious disease physician. The patient tells you they’ve missed several doses of HIV medication in the last month because you’re part of their ongoing care and have earned their trust over time. You tell them it’s important not to miss doses of HIV medication, while making the patient feel safe and comfortable sharing information like this with you in the future.
If you didn’t have this ongoing relationship with the patient and the patient didn’t share this with you, you may have decided to change their HIV medicine to another with greater side effects, even when there was no issue with the original medication. Because you’re part of ongoing care for a single, serious condition or a complex condition such as HIV, and have to weigh these types of factors, the E/M visit is more complex. In this example, you may bill G2211.
G2211 and Modifier 25
G2211 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.
You can add modifier 25 to an E/M CPT code to show the E/M service is significant and separately identifiable from other services you report on the same date of service.
Do’s and Don’ts
Do:
- Analyze if this service is appropriate for your
- Create an internal policy for proper documentation capture and
- Update your charge description master or billing software to capture this
- Furnish provider
- Create an audit process for this service (it’s best practice to review/audit any newly provided service).
Don’t:
- Automate billing this service with all office or other outpatient E/M codes without proper
- Lose sight of the service intent, which is to promote a longitudinal relationship between the provider and patient to improve better care management and positive health
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