Appropriate to apply G2211 in these situations?

[AmiSansNom]

CMS states the G2211 code modifier can be applied to “ongoing medical care related to a patient’s single, serious condition, or complex condition,” and that “G2211 captures the inherent complexity of the visit that’s derived from the longitudinal nature of the practitioner and patient relationship.”

While this is great, I am grappling with some grey areas. I just wanted to get the opinion of the members here as to what you think would be appropriate to apply the G2211 modifier.

Would you agree with my YES/NO in these scenarios below?

A) Metastatic malignancy currently on active induction chemo or immunotherapy or maintenance systemic therapy - YES

B) Metastatic malignancy, completed a period of treatment, currently on clinical/imaging surveillance - YES

C) Early stage cancer on chemotherapy or endocrine therapy - YES

D) Malignancy on targeted therapy - YES

E) MGUS - YES OR NO? - I am seeing them every 3-6 months, so this is ongoing care, but is this serious/complex? What would you do?

F) Iron deficiency anemia, has required parenteral iron a couple of times, being assessed every 6 months with labs to see if they are iron deficient and require PO/parenteral iron - YES? Or NO? If NO, if I am also commenting on their blood pressure or if they have a history of B12 deficiency that is now corrected - would this sway you toward YES?

G) Breast cancer diagnosed 6 years ago - completed 5 years of endocrine therapy - now on annual mammograms and exam and labs - YES or NO? Probably NO? But I am still seeing them long-term yearly, would this qualify for a YES?

H) History of DVT/PE, on apixaban or rivaroxaban, but only seeing them every 6 months or 1 year - YES or NO?

I) ITP patient not on treatment being followed with labs every 3 months - NO maybe?

I am having a bit of a hard time with what I perceive are grey areas in some of the scenarios above. Your opinion or a discussion on these would be quite helpful for us all, I think. Thank you.

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[gutonc]

If you see them once and never again, or are discharging them from clinic, G2211 is not appropriate. In literally every other scenario, it is appropriate.

 

[HemeOncHopeful19]

If they referred them to a sub-specialist (you) then it is complex IMO.

Your government has decided that the legion of NPs are legitimately adequate practitioners of medicine. If something is too complex for them to handle who are you to deem it not complex enough to bill for?

I think (understandably) people often get tripped up by thinking “well this ITP patient is not very complex compared to that patient I saw before them with relapsed Leukemia” but that isn’t what you’re supposed to be comparing it to… you should be thinking “this patient is complex compared to the patient being seen at urgent care for the sniffles receiving a Zpack”

 

[gutonc]

If they referred them to a sub-specialist (you) then it is complex IMO.

Your government has decided that the legion of NPs are legitimately adequate practitioners of medicine. If something is too complex for them to handle who are you to deem it not complex enough to bill for?

I think (understandably) people often get tripped up by thinking “well this ITP patient is not very complex compared to that patient I saw before them with relapsed Leukemia” but that isn’t what you’re supposed to be comparing it to… you should be thinking “this patient is complex compared to the patient being seen at urgent care for the sniffles receiving a Zpack”

This is an excellent assessment. And I think it's something that trips a lot of us up in coding/billing. Just because you, the appropriately trained, certified expert in "it" (whatever "it" is) can manage it in your sleep, doesn't mean that it's not complex. If it wasn't complex, it wouldn't have gotten to you in the first place.

The only people I don't bill G2211 on, aside from the ones I'm d/c'ing from follow up, are the BS abnormal CBCs "eval for acute leukemia" referrals from the NP/PA primary care people that I cure with a repeat CBC. I love walking into the room on the initial consult, raising my hands like a revival preacher and saying "Hallelujah! You're cured!". They laugh, I spend 5 minutes talking about their dog or whatever and I bill a 99204 (without G2211) and go on with my day.

 

[sloh]

The only people I don't bill G2211 on, aside from the ones I'm d/c'ing from follow up, are the BS abnormal CBCs "eval for acute leukemia" referrals from the NP/PA primary care people that I cure with a repeat CBC. I love walking into the room on the initial consult, raising my hands like a revival preacher and saying "Hallelujah! You're cured!". They laugh, I spend 5 minutes talking about their dog or whatever and I bill a 99204 (without G2211) and go on with my day.

But even this could be considered complex haha

 

[gutonc]

But even this could be considered complex haha

Complex yes, but not longitudinal. If I had the time or room on my schedule to have them come back in 6 months for a repeat normal CBC, I'd mash that G2211 button like there was no tomorrow.

 

[AmiSansNom]

Can you use G2211 for a new oncology or heme patient at their initial consultation visit, given that this patient will be under your care for chemotherapy (or for follow-ups every few months if heme like anemia or thrombocytopenia or MGUS)? Wouldn't the longitudinal nature of the physician-patient relationship be established even at the first visit, knowing that you would be seeing them frequently in the future? I am using it for all my follow-up patients (except for ones getting discharged from the clinic), but haven't used it for any new patient. Just wondering.

 

[AmiSansNom]

Can you use G2211 for a new oncology or heme patient at their initial consultation visit, given that this patient will be under your care for chemotherapy (or for follow-ups every few months if heme like anemia or thrombocytopenia or MGUS)? Wouldn't the longitudinal nature of the physician-patient relationship be established even at the first visit, knowing that you would be seeing them frequently in the future? I am using it for all my follow-up patients (except for ones getting discharged from the clinic), but haven't used it for any new patient. Just wondering.

This document here (CMS Implemented G2211 in 2024) states "CMS allows G2211 for new patients, when the practitioner “intends” to have a longitudinal relationship...". So would it be okay to add on the G2211 to all of my new onc and heme patients who I intend on following periodically?

 

[HemeOncHopeful19]

Edit: bah I just saw I already more or less posted this literally 3 posts above, but anyway to reiterate

If I am seeing them and they are going to have a follow up visit, G2211. I truly do believe this was the intent of CMS to increase the RVUs for E/M codes of PCPs and specialists and not for say surgeons or urgent care who might not see a patient longitudinally.

If they are being discharged from clinic/no follow up/want to go to the Academic center in town instead, no G2211.

If they are going to follow with one of the other docs in my group (maybe I’m seeing them because the other guy/gal is out of town for example) then I don’t do G2211 but this one I’m less sure about

 

[gutonc]

Edit: bah I just saw I already more or less posted this literally 3 posts above, but anyway to reiterate

If I am seeing them and they are going to have a follow up visit, G2211. I truly do believe this was the intent of CMS to increase the RVUs for E/M codes of PCPs and specialists and not for say surgeons or urgent care who might not see a patient longitudinally.

If they are being discharged from clinic/no follow up/want to go to the Academic center in town instead, no G2211.

Yeah, we've both answered this question at least once in this thread already. I agree with you wholeheartedly.

If they are going to follow with one of the other docs in my group (maybe I’m seeing them because the other guy/gal is out of town for example) then I don’t do G2211 but this one I’m less sure about

A good question. Easy for me at this point since I'm solo practice (with an NP). But I would argue that it's appropriate to use this code as long as they're being followed longitudinally in the clinic. Just as you can't bill a new patient visit for somebody you've never seen before, but who's followed in your clinic since it's considered ongoing care.

 

[AmiSansNom]

Edit: bah I just saw I already more or less posted this literally 3 posts above, but anyway to reiterate

If I am seeing them and they are going to have a follow up visit, G2211. I truly do believe this was the intent of CMS to increase the RVUs for E/M codes of PCPs and specialists and not for say surgeons or urgent care who might not see a patient longitudinally.

If they are being discharged from clinic/no follow up/want to go to the Academic center in town instead, no G2211.

If they are going to follow with one of the other docs in my group (maybe I’m seeing them because the other guy/gal is out of town for example) then I don’t do G2211 but this one I’m less sure about

Thank you.