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A little background. In 2018, CMS proposed a new focus on E/M documentation guidelines and proposed using a single flat payment rate for office patients, $190.00 for new and $122.00 for established patients. However, those with a personal stake lobbied Congress indicating that data showed that the single payment model would be unfair for some subspecialties. At the same time, CMS proposed an add-on code, which eventually became code G2211, to compensate for specialties likely to be affected most by this payment change, primary care.
Fast forward to 2024, CMS’s single payment proposal has been rescinded and the AMA quickly developed new (and improved) Evaluation and Management (E/M) guidelines largely in response to CMS’s threat of payment changes. An add-on code for increased complexity continued as a CMS initiative.
The implementation of the add-on code was delayed three years in 2020 as part of the 2020 Year-End Funding Bill and COVID-19 Emergency Funding. Although initially considered an add-on code for primary care, CMS emphasized that its use would not be limited to any particular specialty or subspecialty.
While CMS accepted the AMA developed E/M guidelines as developed, CMS still felt that the E/M revisions disadvantaged some practitioners' office visits when treating longitudinal care patients; therefore, they finalized the HCPCS add-on code G2211 for “increased complexity.” Although CMS is not restricting the code's use to certain specialties, the assumption is that some specialties will utilize this code more than others. In the past, many surgical specialties, including AAOS, AANS, ACS, SVS, and fifteen other specialty organizations, have not been strong proponents of this visit-complexity code and, in fact, voiced their concern in a letter to CMS in July 2023. This letter stated that “Implementation of add-on code G2211 would inappropriately result in overpayments and at the same time penalize all physicians.” The concern was that the code would be used inappropriately, leading to inappropriate payments and audits.
Despite specialties concerns, CMS forged ahead with the code and stated in their final fee schedule of 2024:
“CMS believes that the visit complexity add-on code reflects the time, intensity, and practice expense resources involved when practitioners furnish the kinds of E/M office visit services that enable them 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 a patient's health care needs with consistency and continuity over longer periods of time.” (Source: CY 2024 CMS Physician Fee Schedule Final Rule. Page 430.)
The bottom line? This code may also apply in specialty practice settings, where ongoing care is provided for “a single, serious condition or a complex condition.”
What you need to know about code G2211.
- Add-on code G2211 may be reported separately in addition to office/outpatient (E/M) visits for new or established patients (i.e., codes 99202-99215).
- G2211 can also be appropriately added to telehealth visits.
- It should not be used for a visit that includes an E/M with modifier 25 with a minor procedure since additional evaluation time is included in minor procedure CPT codes.
- It would not be reported with managing sprains, strains, fractures, or other outlier visits.
- Medical necessity for using G2211 will be key. Payors will be watching!
CMS's MLN Matters published guidance and examples on "How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211 " on January 18, 2024. CMS’s guidance prompts you to consider the practitioner-patient relationship when using G2211.
Ask yourself the following questions as you consider if this code is appropriate to your patient will help guide you:
- Are you "the continuing focal point for all needed services, like a primary care practitioner?"
- Are you "giving ongoing care for a single, serious condition or a complex condition, like sickle cell disease or HIV?” (e.g., primary care physician specialized in Infectious disease).
What should you do?
- Make sure you fully understand the EM guidelines for office visits!
- Document all the necessary elements of an E/M code to appropriately optimize the level of service and revenues.
- Identify those patient conditions and encounters that might meet the definition of G2211 and develop a plan for implementing and documenting longitudinal, primary-focus care for that subset of patients.
- Note that code G2211 has a current payment of approximately $16 and will likely need specific patient care and documentation requirements.
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Whether you are a primary care physician or a specialist, clearly documenting the medical necessity for the visit and demonstrating your role as the focal point for all needed healthcare services is vital.
KZA suspects the OIG will be following this code usage closely!
Contact KZA to help you and your team optimize your E/M documentation.
Source: https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf.
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