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Who can bill this?
All medical professionals who can bill office and outpatient (O/O) evaluation and management(E/M) visits (CPT codes 99202-99205, 99211-99215), regardless of specialty, may use the code with O/O E/M visits of any level. We don’t restrict G2211 to medical professionals based on specialties.
You can bill this. Its not just for family medicine, internal medicine, PCPs etc
What insurance will pay this? The answer will likely evolve through time. Medicare provides coverage. There is some evidence online that Medicare advantage plans and even some limited commercial plans provide coverage. Below is an example text showing a BCBS plan not providing coverage. The AAFP as the time of my writing this indicates that Cigna (MA), United (commercial/MA), and Humana (commercial/MA) provide coverage.
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For example - BCBS NC including G2211 in their "bundling guidelines" document.
Care Management Services:Care Management Services which include complex chronic care management (99487, 99489, G2211), chroniccare management (99439, 99490, 99491, G0506), transitional care management (99495, 99496), cognitiveassessment and care plan services (99483, 99484), principal care management services (99424, 99425,99426, 99427, 99437), care management services for behavioral health conditions (G0323), chronic pain management and treatment (G3002, G3003) are not eligible for separate reimbursement. Psychiatriccollaborative care management (99492, 99493, 99494, G2214) are not eligible for reimbursement whenperformed by behavioral health provider(s).
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What's it worth? About $16 give or take in private practice + whatever E&M visit you charged.
When can you use this code? The potentially applicable use for a podiatrist is - "Ongoing medical care related to a patient's single, serious condition, or complex condition". Bill G2211 if - "You’re giving ongoing care for a single, serious condition or a complex condition, like sickle cell disease or HIV".
Other medical disciplines are likely to use it for "Serving as the continuing focal point for all of the patients’ health care services needs".
What is the purpose of this code? G2211 captures the inherent complexity of the visit that’s derived from the longitudinal nature of the practitioner and patient relationship.
What the heck does that even mean (...kind of sounds like fluff...)? For almost all my prior answers I've simply copied text straight from the CMS document linked above.
This is an add on code to increase the value of office visits which are perceived as being under compensated. Could they have increased E&M visit values? Yes, but they didn't. This code appears to have began as a PCP/IM/FM type code to take into account the services a PCP provides a patient as their primary that aren't reimbursed through simply billing an E&M code. Below is an advocasy website for Family Medicine where they essentially describe the uncompensated services a PCPs office might provide patient's in addition to whatever the reason that the patient presented for. (Advocacy Focus: G2211 Add-on Code)
Presumably, this code was also primarily intended to benefit non-procedural providers who are perceived to be under compensated (even though Medicare is in general a poor payor of procedures...) because you cannot bill this code if a 25 modifier is also billed.
We're potentially being thrown a bone. Medicine specialties are being thrown a larger bone. Always remember - the last thing we want it to be the medical specialty who is singled out or not allowed to do something. While I usually like to dump on the APMA they in the past fough to prevent podiatry from ending up on a separate E&M system which would have devastated the profession.
Examples of Billing G2211 (from the CMS document)
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 meettheir 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.
What should you as a podiatrist take from Example 1. You aren't a PCP. Replace sinus congestion with plantar fasciitis - the PCP can bill G2211 because they are the PCP. Presumably (possibly, maybe) they also checked the patient's hypertension and asked about their mental health. You could argue that they simply should have billed a higher level E&M code, but the heart of the matter is - the PCP will have more opportunities to bill this code because they can bill it for non-serious conditions. If a FM doctor asked you - are you billing G2211 to people, the answer is - not for the same things they are.
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’simportant not to miss doses of HIV medication, while making the patient feel safe andcomfortable 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 withyou, 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 carefor a single, serious condition or a complex condition such as HIV, and have to weigh thesetypes of factors, the E/M visit is more complex. In this example, you may bill G2211.
How about Example 2? So - I think you could once again be forgiven for reading this and thinking that the patient's non-compliance could theoretically be taken into account via the level of the E&M. That said - we're accepting what we're given. So - here's where things get interesting. The first thing is - there's an "or" in the definition of what you can bill for G2211. So you can bill for a "serious condition" or a "complex condition". Its also worth noting that the word chronic isn't used - I bring that up because chronic is usually the word of choice in the E&M billing table for describing problematic issues ie. "chronic illnesses with exacerbation, progression, or side effects of treatment". That said, the examples we are being given are "HIV" and "sickle cell" so consider carefully what diagnoses will warrant this complexity add on. Consider the following from AAFP:
"CMS has not explicitly defined "single, serious condition, or complex condition." However, they have provided HIV and sickle cell disease as examples. Their guidance emphasizes the importance of the longitudinal relationship and serving as the continuing focal point for all of the patient's health care needs. The complexity captured by G2211 is not related to the condition itself. Further, CMS notes, "Add-on code G2211 includes services that enable practitioners to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single, high-risk disease) and to address the majority of patients' health care needs with consistency and continuity over long periods of time.”
Can I bill a CPT code and an E&M code and G2211 (ie. a 25 modifier encounter)? As already described above, no.
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.
Does G2211 require extra documentation? Not at this time. The documentation needs to be sufficient to justify the medical necessity of the E&M code.
What are other examples where you would not bill G2211?
"Your relationship with the patient is of a discrete, routine, or time-limited nature. For example, a physician who sees a patient for an acute concern should not report HCPCS G2211 if they have not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time."
G2211 Add-on Code: What It Is and How to Use It
The care you provide your patients is complex and comprehensive. G2211 will help you get paid more accurately for it.
What other resources are out there? The CMS document referenced above is literally the source document that my MAC points. My most recent conversation with a podiatry specific professional coder was - "Ignore online posters (...me) and go to your MACs LCD". Well, Novitas doesn't have much.
Noridian used the following language, some of which I had not previously encountered:
"Documentation would support furnishing services to patients on an ongoing basis that result in care personalized to the patient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape. The complexity code would support a long-term patient-provider relationship and would indicate the provider will be managing the health care over a long period of time. The provider would build the trusting relationship and be the continuing focal point for all needed health care services related to the ongoing patient’s single, serious condition or complex condition. Every patient would be unique with their health care needs and templated language for the add-on code may not support medical necessity."
Coding Intel has an informative page with a video and some discussion of feedback provided from CMS - for example that they expect 54% of visits to include a G2211 in the future (though obviously not applicable to all specialties).
CMS Implemented G2211 in 2024
CMS implemented add-on code G2211 in 2024. This code is for practitioners who use E/M services to report most of their services. CMS believes
codingintel.com
CMS says not to use G2211 in these examples:
Last of all. See the Meme thread.
