Billing-new code

[hehe5347]

Anyone have experience with the G2211 code- do you use it with new patients or follow ups or both? Which types of patients are you using it for? Thanks!

---

Members don't see this ad.

 

[gutonc]

Anyone have experience with the G2211 code- do you use it with new patients or follow ups or both? Which types of patients are you using it for? Thanks!

This is honestly the first I've heard of it...and I like it.

Reading through the AAFP and CMS pages on it, it seems like the sort of thing you'd use for any patient on active treatment, for follow up (not initial visit since you're never really sure if somebody's sticking with you until they do). I'm not sure I'd do it for non-treatment patients since it's hard to say you're the "the continuing focal point for all needed services, or are part of ongoing care related to a patient’s single, serious condition or a complex condition" for some of the benign heme stuff we see, or long-term follow up of breast or colon cancer (when their PCP, surgeon, GI, etc) are also doing the same.

But it seems like a slam dunk for any of your chemo players. I'm going to start using it when I get back from vacation next week and I'll let you know how hard my coders come down on me for it.

 

[whoknows2012]

Our guidance was basically that it can and should be used on just about anyone who has active malignancy being treated or followed even if in remission/ned. Patients to not use it in for example (as suggestions from the compliance folks) were patients >5 yrs out coming in for yearly surveillance (depending on dz type) or patients that are requiring very little time ie a lab check or the like

 

[bobsmith]

We had a training session on this and also were given pretty broad instructions on its use, particularly given how complex our patients can be and how often other physicians will want our "clearance" before proceeding with even minor things.

ASCO Practice Impact Analysis of 2024 Medicare Physician Fee Schedule Proposed Rule makes it also seem like CMS expects us to use it quite a bit (for medicare patients, at least)

In the CY 2021 MPFS final rule, CMS increased the valuation of office/outpatient visits and added a new add-on code, G2211 for complex visits. For 2021, CMS assumed that hematology/oncology would add G2211 to 90% of visits

 

[RainerMaria]

How much will this add per visit RVU wise?

Also can we use it on benign heme patients? Some can be fairly complex and be seen quarterly and with multiple issues that you are coordinating.

 

[HemeOncHopeful19]

Even 80% of my benign heme patients see me more than any other doc

 

[bobsmith]

How much will this add per visit RVU wise?

Also can we use it on benign heme patients? Some can be fairly complex and be seen quarterly and with multiple issues that you are coordinating.

0.33 wRVU for G2211

The rule is designed to cover "longitudinal care of complex patients" and so definitely applicable for certain non-malignant heme patients, too. I used it for active ITP pt today

 

[Duke1K]

Unrelated but a billing question - my understanding of the main differences between the add-on codes for prolonged visits, 99417 and G2212, is that 99417 can be billed at the minimum time interval allowed (i.e., 75min with 99205) and G2212 can only be billed 15min after the max (i.e., 89min with 99205). Also, 99417 is non-Medicare and G2212 is Medicare payers though not exclusively.

In practice, how would you bill for a 90min encounter with a new patient? Can you add both 99417 and G2212 and let the payers sort out which is appropriate?

 

[hehe5347]

This is honestly the first I've heard of it...and I like it.

Reading through the AAFP and CMS pages on it, it seems like the sort of thing you'd use for any patient on active treatment, for follow up (not initial visit since you're never really sure if somebody's sticking with you until they do). I'm not sure I'd do it for non-treatment patients since it's hard to say you're the "the continuing focal point for all needed services, or are part of ongoing care related to a patient’s single, serious condition or a complex condition" for some of the benign heme stuff we see, or long-term follow up of breast or colon cancer (when their PCP, surgeon, GI, etc) are also doing the same.

But it seems like a slam dunk for any of your chemo players. I'm going to start using it when I get back from vacation next week and I'll let you know how hard my coders come down on me for it.

But apparently you can’t use it the same day as someone getting an infusion?
Can anyone verify this? I see my super complex chemo pts the same day as their infusion so it would be disappointing not to be able to do so

 

[Duke1K]

But apparently you can’t use it the same day as someone getting an infusion?
Can anyone verify this? I see my super complex chemo pts the same day as their infusion so it would be disappointing not to be able to do so

Source: https://www.cms.gov/files/document/...luation-and-management-visit-and-modifier.pdf

"For CY 2024, with the end of the Congressional mandated suspension of payment for O/O E/M visit complexity add-on code G2211, CMS finalized a rule to make the code separately payable by assigning the active status indicator to it, effective January 1, 2024.

Separately identifiable visits occurring on the same day as minor procedures, such as zero-day global procedures, have resources sufficiently distinct from the costs associated with providing stand-alone O/O E/M visits to justify different payment.

Therefore, we finalized the rule that the O/O E/M visit complexity add-on code G2211 isn’t payable when you report the O/O E/M visit with payment modifier 25."

 

[whoknows2012]

But apparently you can’t use it the same day as someone getting an infusion?
Can anyone verify this? I see my super complex chemo pts the same day as their infusion so it would be disappointing not to be able to do so

I believe that was our guidance-or same day as procedure (ie bmbx )

 

[solidonc2020]

Sounds like a really nice bump for chronic management of prostate or breast cancer patients on hormonal/endocrine therapies.

 

[gutonc]

Source: https://www.cms.gov/files/document/...luation-and-management-visit-and-modifier.pdf

"For CY 2024, with the end of the Congressional mandated suspension of payment for O/O E/M visit complexity add-on code G2211, CMS finalized a rule to make the code separately payable by assigning the active status indicator to it, effective January 1, 2024.

Separately identifiable visits occurring on the same day as minor procedures, such as zero-day global procedures, have resources sufficiently distinct from the costs associated with providing stand-alone O/O E/M visits to justify different payment.

Therefore, we finalized the rule that the O/O E/M visit complexity add-on code G2211 isn’t payable when you report the O/O E/M visit with payment modifier 25."

Our infusion unit is functionally a completely separate hospital department and infusion billing happens separately. I wonder if that's enough to make it do-able for chemo patients. We have gotten exactly no guidance on this from my system. I'll definitely bring it up at my next department and hospital gen staff meetings.

On a related note, I tried to figure out how to add this code in Epic and couldn't figure out a way to make it work in the instance of Epic we're using. That suggests to me that our institution hasn't "turned it on" yet...which is stupid.

 

[skyblue2000]

Our infusion unit is functionally a completely separate hospital department and infusion billing happens separately. I wonder if that's enough to make it do-able for chemo patients. We have gotten exactly no guidance on this from my system. I'll definitely bring it up at my next department and hospital gen staff meetings.

On a related note, I tried to figure out how to add this code in Epic and couldn't figure out a way to make it work in the instance of Epic we're using. That suggests to me that our institution hasn't "turned it on" yet...which is stupid.

I asked my hospital and that’s exactly what they said.
They’re still investigating it and it hasn’t been activated yet.

 

[terribletwos]

Speaking of billing, has anyone had any issues billing visits the same day as clearance / chemo clearance? Do folks use modifier 25 or just bill regularly? We have started to see issues with this and not sure if it is commercial, medicare, or both pushing back on this. This could have major implications for how we get our E/M reimbursed as a lot of it is done same day as chemo / chemo clearance. There is some language that it has to be a separately identifiable and significant visit and can't just bill for "chemo clearance." I.e., only visits where pt is having a major problem with chemo may get reimbursed. Some places are more strict about this than others.

 

[solidonc2020]

Our infusion unit is functionally a completely separate hospital department and infusion billing happens separately. I wonder if that's enough to make it do-able for chemo patients. We have gotten exactly no guidance on this from my system. I'll definitely bring it up at my next department and hospital gen staff meetings.

On a related note, I tried to figure out how to add this code in Epic and couldn't figure out a way to make it work in the instance of Epic we're using. That suggests to me that our institution hasn't "turned it on" yet...which is stupid.

I’m a fellow for 5 more months so don’t do billing regularly, but I did see the option to click and add it on in Epic for our system today FYI. Attending had never heard anything about it.

 

[brentux1985]

Speaking of billing, has anyone had any issues billing visits the same day as clearance / chemo clearance? Do folks use modifier 25 or just bill regularly? We have started to see issues with this and not sure if it is commercial, medicare, or both pushing back on this. This could have major implications for how we get our E/M reimbursed as a lot of it is done same day as chemo / chemo clearance. There is some language that it has to be a separately identifiable and significant visit and can't just bill for "chemo clearance." I.e., only visits where pt is having a major problem with chemo may get reimbursed. Some places are more strict about this than others.

I'm a new attending so hoping seniors can comment here, but I have been taught to see patient's a few days before treatment to avoid any billing mishaps. This was both at my old academic institution and now in private sector.

Patient's don't mind at all and prevents drug waste/rescheduling mishaps.

 

[gutonc]

I'm a new attending so hoping seniors can comment here, but I have been taught to see patient's a few days before treatment to avoid any billing mishaps. This was both at my old academic institution and now in private sector.

Patient's don't mind at all and prevents drug waste/rescheduling mishaps.

I have a large number of patients who drive from up to 3 hours away to see me so they definitely mind having to make 2 trips.

Our drugs aren't mixed until I give the OK to the nurses and pharmacy after seeing the patient, so we don't really have issues with drug wasting. If they wind up having treatment held, they only made the one trip they'd have to in the first place.

The billing issue will depend on how your institution is set up. I never experienced problems with this in my academic, academ-ish or rural hospital-based practices.

 

[gutonc]

Just to follow up, a G2211 button magically appeared in my Epic billing section today. I'm clicking the **** out of it today.

We also had a quarterly staff meeting on Monday (that I didn't make it to) that included coding updates, including G2211, and got the slides from today. At least in my state, we're only billing this on CMS patients, but we are billing it on anything that's not a "one and done" second opinion. So new patients who will follow up with us, whether they need treatment or not, are fair game for this one.

 

[solidonc2020]

Just to follow up, a G2211 button magically appeared in my Epic billing section today. I'm clicking the **** out of it today.

We also had a quarterly staff meeting on Monday (that I didn't make it to) that included coding updates, including G2211, and got the slides from today. At least in my state, we're only billing this on CMS patients, but we are billing it on anything that's not a "one and done" second opinion. So new patients who will follow up with us, whether they need treatment or not, are fair game for this one.

Our group has been told to click it for everyone that isn't one and done and let the coders figure it out from there.

ETA: Curious if your usual math which assumes 2 wRVUs per average oncology patient will be bumped up, maybe closer to 2.2 now?

 

[gutonc]

Our group has been told to click it for everyone that isn't one and done and let the coders figure it out from there.

ETA: Curious if your usual math which assumes 2 wRVUs per average oncology patient will be bumped up, maybe closer to 2.2 now?

Actually just came here to say, I'm mashing that button like nobody's business this week and my wRVU/encounter are floating around 2.4. For last year they were a hair over 2.1.

I still think 2 is a nice easy number to deal with, but I suspect we'll see things crawling upward over time.

 

[NewYorkDoctors]

anyone who is curious how much this is in dollar bills

this is something from my EMR's fee schedule

Medicare	Medicaid	Commercial	HMO	SelfPay	Fee6	Fee7	Fee8	Fee9	Fee10
CPT Code	Modifier	CPT Name	Medicare NY Area1	My Fee Schedule
G2211​		Complex e/m visit add on	19.60​	19.60​

 

[hehe5347]

Actually just came here to say, I'm mashing that button like nobody's business this week and my wRVU/encounter are floating around 2.4. For last year they were a hair over 2.1.

I still think 2 is a nice easy number to deal with, but I suspect we'll see things crawling upward over time.

Do you think you can use it for “leukopenia” “iron deficiency anemia” or other benign heme cases?

 

[chessknt]

Do you think you can use it for “leukopenia” “iron deficiency anemia” or other benign heme cases?

I think the spirit of this code was for complex condition management, not literally the management of any condition but it seems rampant abuse is the only lever providers have left to get any kind of reimbursement from CMS. I imagine this code will be annihilated next year if every speciality bills it for every condition they manage and well only have ourselves to blame when you actually do a ton of work on a hard patient and don't have anything beyond E/M time to look at for it.

 

[HemeOncHopeful19]

I think the spirit of this code was for complex condition management, not literally the management of any condition but it seems rampant abuse is the only lever providers have left to get any kind of reimbursement from CMS. I imagine this code will be annihilated next year if every speciality bills it for every condition they manage and well only have ourselves to blame when you actually do a ton of work on a hard patient and don't have anything beyond E/M time to look at for it.

I think there’s argument to be made that this code is essentially “yes, we realize urgent cares could be replaced by a vending machine. Here is a way to start splitting out their reimbursement from the regular docs”

 

[gutonc]

I think there’s argument to be made that this code is essentially “yes, we realize urgent cares could be replaced by a vending machine. Here is a way to start splitting out their reimbursement from the regular docs”

Similarly, I think it's an attempt to recognize that there is value to the patient and the system, in providing this kind of longitudinal care, whether it's complex or not, as it can help reduce the use of higher cost resources such as urgent care and ED care since a 99213+G2211 is cheaper than a 99203 or whatever the ED would bill for it.

It's hard to argue it won't get overused. But I appreciate the idea behind it and will use it appropriately.

 

[hehe5347]

Hey everyone,
Just wanted to clarify in case someone sees this thread in the future- I checked with our billing people and apparently in my clinic you can use G2211 with patients getting chemo the same day because the modifier 25 is being billed on the hospital side, not the professional side. So it’s worth talking to your coding people bc you may get to use it even more!

 

[randomhemoncpd]

Hey everyone,
Just wanted to clarify in case someone sees this thread in the future- I checked with our billing people and apparently in my clinic you can use G2211 with patients getting chemo the same day because the modifier 25 is being billed on the hospital side, not the professional side. So it’s worth talking to your coding people bc you may get to use it even more!

Thanks for the tip. I will discuss with our coding / compliance team.

 

[dozitgetchahi]

Hey everyone,
Just wanted to clarify in case someone sees this thread in the future- I checked with our billing people and apparently in my clinic you can use G2211 with patients getting chemo the same day because the modifier 25 is being billed on the hospital side, not the professional side. So it’s worth talking to your coding people bc you may get to use it even more!

Rheumatologist here.

So am I understanding that if I see a patient in clinic on the same day I send them to infusion, I can use modifier 25?

The G2211 bit is very interesting and I used it today on several complex patients that I follow closely (lupus, vasculitis)…we will see if the billers give me **** for it.

 

[RainerMaria]

I am learning that modifier 25 is used unnecessarily in most practices UNLESS you own the infusion and you are the provider billing both for the infusion and the E/M. Per AAPC, NCCI rules apply to codes submitted on the same date by the same provider. Even HHS/OIG says modifier 25 is submitted unecessarily in these cases. The giveaway is if in EPIC you look closely it is the infusion nurse (or other infusion lead) who is listed as service provider for the infusion charges/codes, where as you are service provider for the office visit E/M charges under your clinic (separate encounter). Completely separate and this allows for same-day billing in chemo that most cancer centers do. So if you are in the majority of settings where you are not the service provider for the infusion codes, then G2211 should be fine to submit alongside your same-day E/M day of chemo.

If you are in the camp that does own infusion/same provider, then you do need to submit modifier 25 for a significant and separately identifiable event such as significant derangement in labs causing you to adjust/stop infusion, etc, or otherwise treating an infection or doing something new. Can't just be routine clearance for infusion. The latter attracts the ire of HHS/OIG and they are cracking down on overuse/abuse in these cases.

https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

"OIG divided claims submitted with modifier 25 into two groups: those that had no other claim for the same beneficiary on the same day for the same provider and those that did. Physicians who submitted claims included in the first group used modifier 25 unnecessarily because no other claims were submitted for the beneficiaries on the dates of those services. "

 

[HemeOncHopeful19]

I am learning that modifier 25 is used unnecessarily in most practices UNLESS you own the infusion and you are the provider billing both for the infusion and the E/M. Per AAPC, NCCI rules apply to codes submitted on the same date by the same provider. Even HHS/OIG says modifier 25 is submitted unecessarily in these cases. The giveaway is if in EPIC you look closely it is the infusion nurse (or other infusion lead) who is listed as service provider for the infusion charges/codes, where as you are service provider for the office visit E/M charges under your clinic (separate encounter). Completely separate and this allows for same-day billing in chemo that most cancer centers do. So if you are in the majority of settings where you are not the service provider for the infusion codes, then G2211 should be fine to submit alongside your same-day E/M day of chemo.

If you are in the camp that does own infusion/same provider, then you do need to submit modifier 25 for a significant and separately identifiable event such as significant derangement in labs causing you to adjust/stop infusion, etc, or otherwise treating an infection or doing something new. Can't just be routine clearance for infusion. The latter attracts the ire of HHS/OIG and they are cracking down on overuse/abuse in these cases.

https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

"OIG divided claims submitted with modifier 25 into two groups: those that had no other claim for the same beneficiary on the same day for the same provider and those that did. Physicians who submitted claims included in the first group used modifier 25 unnecessarily because no other claims were submitted for the beneficiaries on the dates of those services. "

So basically it’s another way big hospital groups can charge more while private practice gets the shaft?

Awesome, we definitely need more of that in 2024

 

[bronx43]

I think the spirit of this code was for complex condition management, not literally the management of any condition but it seems rampant abuse is the only lever providers have left to get any kind of reimbursement from CMS. I imagine this code will be annihilated next year if every speciality bills it for every condition they manage and well only have ourselves to blame when you actually do a ton of work on a hard patient and don't have anything beyond E/M time to look at for it.

They already dropped the conversion factor across the board. This code is basically a way for CMS to shift a bit of money from procedural to E&M. The surgical specialties were protesting this when it was proposed.

19 Surgical Organizations Strongly Oppose CMS’ Plan to Implement the G2211 Code

Implementation of add-on code G2211 would inappropriately result in overpayments and at the same time penalize all physicians.

www.facs.org

And CMS expects a significant percent of visits to carry G2211. I highly doubt the code goes anywhere. They may simply reduced the amount it pays...

 

[HemeOncHopeful19]

The surgical specialties were protesting this when it was proposed.

19 Surgical Organizations Strongly Oppose CMS’ Plan to Implement the G2211 Code

Implementation of add-on code G2211 would inappropriately result in overpayments and at the same time penalize all physicians.

www.facs.org

 

[bronx43]

View attachment 383095

Those guys get 15k facility fee for one TKA. They can go cry a river about our $19 clinic code.

 

[Duke1K]

I am learning that modifier 25 is used unnecessarily in most practices UNLESS you own the infusion and you are the provider billing both for the infusion and the E/M. Per AAPC, NCCI rules apply to codes submitted on the same date by the same provider. Even HHS/OIG says modifier 25 is submitted unecessarily in these cases. The giveaway is if in EPIC you look closely it is the infusion nurse (or other infusion lead) who is listed as service provider for the infusion charges/codes, where as you are service provider for the office visit E/M charges under your clinic (separate encounter). Completely separate and this allows for same-day billing in chemo that most cancer centers do. So if you are in the majority of settings where you are not the service provider for the infusion codes, then G2211 should be fine to submit alongside your same-day E/M day of chemo.

If you are in the camp that does own infusion/same provider, then you do need to submit modifier 25 for a significant and separately identifiable event such as significant derangement in labs causing you to adjust/stop infusion, etc, or otherwise treating an infection or doing something new. Can't just be routine clearance for infusion. The latter attracts the ire of HHS/OIG and they are cracking down on overuse/abuse in these cases.

https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

"OIG divided claims submitted with modifier 25 into two groups: those that had no other claim for the same beneficiary on the same day for the same provider and those that did. Physicians who submitted claims included in the first group used modifier 25 unnecessarily because no other claims were submitted for the beneficiaries on the dates of those services. "

The definition of "same provider" is important - CMS considers physicians (and I'm guessing any provider - APP or otherwise) of the same specialty in the same group practice as the same physician.

 

[RainerMaria]

True. In most settings of hospital based chemo, NP/PA/Physician that are part of the medical practice are not submitting infusion charges and so this shouldn't be an issue. Infusion nurses submitting charges would not be the same practice and therefore not the same provider.

 

[bigboyonc]

Anyone been told patients are receiving a bill from Medicare for $15 for this new code?

 

[gutonc]

Anyone been told patients are receiving a bill from Medicare for $15 for this new code?

No. But NMFP anyway. The hospital and CMS can deal with that. If the code is there, I'm using it.